COLUMBIAXIBRARIES  OFFSITE 

HEALTH^CIENCES  STANDARD 


HX64085775 
QM531  .T72  1 901    Surgical  applied  ana 


'tomy 


F.  Treves.  ERCS. 


QJTLS^I 


T7^ 


Columbia  ©ntoem'tp 

College  of  iPfesictang  ano  Hmrgeons 
Htbrarp 


SURGICAL 

Applied  Anatomy 


BY 

SIR     FREDERICK     TREVES 

K.C.V.O.,    C.B.,     F.R.C.S. 

SERGEANT  SURGEON    TO    H.M.    THE    KING 

SURGEON   IN   ORDINARY   TO    H.R.H.    THE    DUKE   OP   CORNWALL    AND    YORK 

CONSULTING    SURGEON   TO   THE   LONDON    HOSPITAL 

LATE    LECTURER   ON    ANATOMY   AT   THE    LONDON    HOSPITAL 

N  E  W    E  D  IT  ION,     REVISED    BY    T  II  E    A  V  THO  R 

WITH    THE    ASSISTANCE    OF 

ARTHUR     KEITH,     M.D.,     F.R.C.S. 

LECTURER    ON   AND    SENIOR    DEMONSTRATOR     OF    ANATOMY    AT   THE 
LONDON    HOSPITAL 


PHILADELPHIA 

LEA     BROTHERS     &     CO. 


7^ 


io\ 


PREFACE    TO    THE    PRESENT    EDITION. 


In  the  present  edition  the  work  has  been  carefully 
revised  throughout ;  certain  sections  have  been  re- 
written, and  much  new  matter  has  been  added.  Every 
effort  has  been  made  to  bring  each  chapter  of  the  book 
well  up  to  date.  Many  new  woodcuts  have  been  added 
or  have  replaced  the  illustrations  used  in  previous 
editions. 


F.  T. 
A.  K. 


London  Hospital, 
May,  1901. 


PREFACE   TO   THE    FIRST    EDITION. 


Ai'J'lied  Anatomy  has,  1  imagine,  a  twofold  function. 
On  the  one  hand  it  serves  to  give  a  precise  basis  to 
those  incidents  and  procedures  in  practice  that  more 
especially  involve  anatomical  knowledge  ;  on  the  other 
hand  it  endues  the  dull  items  of  that  knowledge  with 
meaning  and  interest  by  the  aid  of  illustrations  drawn 
from  common  medical  and  surgical  experience.  In  this 
latter  aspect  it  bears  somewhat  the  same  relation  to 
Systematic  Anatomy  that  a  series  of  experiments  in 
Physics  bears  to  a  treatise  dealing  with  the  bare  data 
of  that  science. 

The  student  of  Human  Anatomy  has  often  a  nebul<  rus 
notion  that  what  he  is  learning  will  sometime  prove 
of  service  to  him ;  and  may  be  conscious  also  that  the 
study  is  a  valuable,  if  somewhat  unexciting,  mental 
exercise.  Beyond  these  impressions  he  must  regard 
his  efforts  as  concerned  merely  in  the  accumulation 
of  a  number  of  hard  unassimilable  facts.  It  should  be 
one  object  of  Applied  Anatomy  to  invest  these  facts 
with  the  interest  derived  from  an  association  with  the 
circumstances  of  daily  life  ;  it  should  make  the  dry 
bones  live. 

It  must  be  owned  also  that  all  details  in  Anatomy 
have  not  the  same  practical  value,  and  that  the  memory 
of  many  of  them  may  [fade  without  loss  to  the  com- 
petency of  the  practitioner  in  medicine  or  surgery.  It 
should  be  one  other  object,  therefore,  of  a  book  having 
such  a  purpose  as  the  present,  to  assist  the  student  in 
judging  of  the  comparative  value  of  the  matter  he  has 
learnt ;  and  should  help  him,  when  his  recollection  of 
anatomical  facts  grows  dim,  to  encourage  the  survival 
of  the  fittest. 


x  Preface. 

In  writing  this  manual  I  have  endeavoured,  so  far 
as  the  space  at  my  command  would  permit,  to  carry 
out  the  objects  above  described  ;  and  while  I  believe 
that  the  chief  matters  usually  dealt  with  in  works  on 
Surgical  Anatomy  have  not  been  neglected,  I  have 
nevertheless  tried  to  make  the  principle  of  the  book  the 
principle  that  underlies  Mr.  Hilton's  familiar  lectures 
on  "  Best  and  Pain." 

I  have  assumed  that  the  reader  has  some  knowledge 
of  Human  Anatomy,  and  have  not  entered,  except  in  a 
few  instances,  into  any  detailed  anatomical  descriptions. 
The  bare  accounts,  for  example,  of  the  regions  .con- 
cerned in  Hernia  I  have  left  to  the  systematic  treatises, 
and  have  dealt  only  with  the  bearings  of  the  anatomy 
of  the  parts  upon  the  circumstances  of  practice.  The 
limits  of  space  have  compelled  me  to  omit  all  those  parts 
of  the  "  Surgery  of  the  Arteries  "  that  deal  with  ligature, 
collateral  circulation,  abnormalities,  and  the  like.  This 
omission  I  do  not  regret,  since  those  subjects  are  fully 
treated  not  only  in  works  on  operative  surgery  but  also 
in  the  manuals  of  general  anatomy. 

The  book  is  intended  mainly  for  the  use  of  students 
preparing  for  their  final  examination  in  surgery.  I 
hope,  however,  that  it  will  be  of  use  also  to  practitioners 
whose  memory  of  their  dissecting-room  work  is  growing 
a  little  gray,  and  who  would  wish  to  recall  such  ana- 
tomical matters  as  have  the  most  direct  bearing  upon 
the  details  of  practice.  Moreover,  it  is  possible  that 
junior  students  may  find  some  interest  in  the  volume, 
and  may  have  their  studies  rendered  more  intelligent, 
by  learning  how  anatomy  is  concerned  in  actual  dealings 
with  disease. 

Frederick  Treves. 
Sept.,  1883. 


CONTENTS 


PART    L—  THE    HEAD    AND    NECK. 

CHAPTER 

I. — The  Scalp       ...... 


II. — The  Bony  Vault  of  the  Cranium 
III. — The  Cranial  Contents 
IV. — The  Orbit  and  Eye 

V— The  Ear 

VI.— The  Nose  and  Nasal  Cavities   . 

VII.— The  Face 

VIII.— The  Mouth,  Tongue,  Palate,  and  Pharynx 
IX.— The  Neck 


PART    II. 


X.— The  Thorax 


PAGE 
1 

15 

28 
41 
08 
81 
95 
117 
135 


168 


PART    III. -THE    UPPER    EXTREMITY. 

XL— The  Region  of  the  Shoulder     ....    185 
XII.— The  Arm 223 


XI I 


Surgical    Applied    Anatomy. 


CHAPTER 

XIII. — The  Region  of  the  Elbow 
XIV.— The  Fore- arm 
XV. — The  Wrist  and  Hand  . 


PAGE 

230 
24fi 
253 


PART    IV.— THE    ABDOMEN    AND    PELVIS. 

XVI.— The  Abdomen 282 

XVII. — The  Abdominal  Viscera 31H 

XVIII.— The  Pelvis  and  Perineum 372 


PART    V.— THE    LOWER    EXTREMITY 
XIX.— The  Region  of  the  Hif 

XX.— The  Thigh 

XXL— The  Region  of  the  Knee    . 

XXII.— The  Leg 

XXIII. —The  Ankle  and  Foot    . 


423 

458 
4G5 
489 
500 


PART    VI. 


XXIV.— The  Spine 
Index 


537 
557 


(Surgical  Applied  Anatomy 
tart  ft. 

The     Head    a  n  d    X'eck. 


CHAPTER    I. 

THE    SCALP. 

The  soft  parts  covering  the  vault  of  the 
skull  may  be  divided  into  five  layers  :  (1)  the  skin, 
(2)  the  subcutaneous  fatty  tissue,  (3)  the  occipito- 
frontalis  muscle  and  its  aponeurosis,  (4)  the  sub- 
aponeurotic connective  tissue,  and  (5)  the  pericranium. 
It  is  convenient  to  consider  the  term  "  scalp "  as 
limited  to  the  structure  formed  by  the  union  of  the 
first  three  layers  above  named  (Fig.  1). 

The  skin  of  the  scalp  is  thicker  than  it  is  in  any 
other  part  of  the  body.  It  is  in  all  parts  intimately 
adherent,  by  means  of  the  subcutaneous  tissue,  to  the 
aponeurosis  and  muscle  beneath  it,  and,  from  this 
adhesion,  it  follows  that  the  skin  moves  in  all  move- 
ments of  that  muscle.  The  subcutaneous  tissue  is,  like 
a  similar  tissue  in  the  palm,  admirably  constructed  to 
resist  pressure,  being  composed  of  a  multitude  of  fibrous 
bands  enclosing  fat  lobules  in  more  or  less  isolated 
spaces  (Fig.  1,  b).  The  density  of  the  scalp  is  such,  that  in 
surface  inflammations,  such  as  cutaneous  erysipelas,  it 
is  unable  to  present  (except  in  a  very  slight  degree) 
two  conspicuous  features  of  such  inflammations,  viz., 
redness  and  swelling.  The  skin  is  provided  with  a 
great  number  of  sebaceous  glands,  which  may  develop 


2  Surgical    Applied    Anatomy.      [Chap.  i. 

into  cystic  tumours  or  wens,  such  cysts  being  more 
common  upon  the  scalp  than  in  any  other  part  of  the 
body.  Being  skin  growths,  these  cysts,  even  when 
large,  remain,  except  in  rare  instances,  entirely  out- 
side the  aponeurosis,   and   can  therefore   be   removed 


Fig,  1. — Diagram  showing  the  Layers  of  the  Scalp  and  Membranes  of 
the  Brain  in  Section. 

a,  Skin ;  b,  subcutaneous  tissue  with  hair  roots  and  vessels;  c,  epicranium 
a,  sub-aponeurotic  layer  ;  e,  pericranium  ;  '/,  parietal ;  g,  dura  mater ;  /.•,  arach- 
noid ;  l;  pia  mater  ;  m,  cortex  ;  n,  in  subdural  space  near  a  Pacchionian  body 
projecting  within  the  superior  longitudinal  sinus. 

without  risk  of  opening  up  the  area  of  loose  con- 
nective tissue  between  the  aponeurosis  and  the  peri- 
cranium. 

There  being  no  fatty  tissue  in  any  of    the  layers 
that   nover  the  bony  vault    save  in  the  subcutaneous 


Chap,  i.]  The    Scalp.  3 

liver,  it.  happens  that  in  cases  of  obesity  the  scalp 
undergoes  but  little  change,  the  fat  in  the  subcu- 
taneous tissue  being  limited  by  the  dense  fibrous 
structures  that  enclose  it.  For  the  same  reasons  fatty 
tumours  of  the  scalp  arc  very  rare.  The  attachment 
of  the  hairs  collectively  to  the  scalp  is  so  strong  that 
there  are  many  cases  where  the  entire  weight  of  the 
body  has  been  supported  by  the  hair  of  the  scalp. 
Agnew  records  the  case  of  a  woman  whose  hair 
became  entangled  in  the  revolving  shaft  of  a  machine. 
The  hair  did  not  give  way,  but  the  entire  scalp  whs 
torn  off  from  the  skull.  The  patient  recovered.  I 
have  seen  a  precisely  similar  case  in  a  girl  aged  1.3. 
(Museum,  R.  Coll.  Surgeons,  87  F.) 

The  dangerous  area  of  the  scalp.— Between 
the  aponeurosis  and  the  pericranium  is  an  extensive 
layer  of  loose  connective  tissue,  that  may,  for  reasons 
to  be  presently  given,  be  fairly  called  the  dangerous 
area  of  the  scalp  (Fig.  1,  d).  The  mobility  of  the 
scalp  depends  entirely  upon  the  laxity  of  this  layer  of 
tissue.  In  extensive  scalp  wounds,  when  a  part  of 
the  scalp  is  separated  in  the  form  of  a  large  flap,  a 
flap  that  may  hang  down  and  cover  half  the  face,  it 
is  the  very  looseness  of  this  tissue  that  permits  such 
separation.  In  the  Indian  process  of  scalping,  a 
taste  that  is  becoming  one  of  the  past,  the  much- 
prized  piece  of  skin  is  torn  from  the  skull  through 
this  lax  area  of  connective  tissue,  and,  were  there  no 
such  area,  scalping  would  be  an  operation  requiring 
some  time  and  art. 

The  exposure  of  the  skull  in  a  post-mortem  exami- 
nation is  effected  by  peeling  off  the  seal])  along 
this  layer  of  loose  tissue,  and  it  is  remarkable  with 
what  ease  the  skull  can  be  exposed  by  this  manoeuvre. 
Sutures  may  be  safely  applied  to  adjust  scalp 
wounds,  provided  they  are  not  too  long  retained. 
They  probably  include  the  aponeurosis,  and  if  long 
retained  may  act  as  setons  and  set  up  suppuration, 
which  may  find  its  way  into  the  loose  layer  beneath 
the  aponeurosis. 


4  Surgical    Applied    Anatomy.      [Chap.  i. 

Wounds  of  the  scalp  never  gape,  unless 
the  wound  lias  involved  the  scalp  muscle  or  its 
aponeurosis.  When  this  structure  has  been  divided 
the  lax  layer  beyond  permits  of  great  separation  of 
the  edges  of  even  the  simplest  wounds.  In  uncompli- 
cated incised  wounds,  the  amount  of  gaping  of  the 
cut  depends  upon  the  action  of  the  occipito-frontalis 
muscle.  Those  wounds  gape  the  most  that  are  made 
across  the  muscle  itself,  and  that  are  transverse  to  the 
direction  of  its  fibres,  while  those  show  the  least 
separation  that  involve  the  aponeurosis  and  are  made 
in  an  antero-posterior  direction.  The  mobility  of  the 
scalp  is  more  marked  in  the  young  than  in  the  old. 
A  case  recorded  by  Agnew  serves  in  a  strange  degree 
to  illustrate  this  fact  in  the  person  of  an  infant.  A 
midwife  attending  a  woman  in  labour  mistook  the 
scalp  of  the  infant  for  the  membranes,  and  gashed  it 
with  a  pair  of  scissors.  Labour  pains  came  on  and  the 
head  was  protruded  through  the  scalp  wound,  so  that 
the  whole  vault  of  the  skull  was  peeled  like  an  orange. 
The  scalp  being  firmly  stretched  over  the  hard 
cranium  beneath,  it  follows  that  contused  wounds 
often  appear  as  cleanly  cut  as  are  those  that  have  been 
made  by  an  incision.  Such  wounds  may  be  compared 
to  the  clean  cut  that  may  be  made  in  a  kid  glove  when 
it  is  tightly  stretched  over  the  knuckles  and  those 
parts  are  sharply  rapped. 

The  scalp  is  extremely  vascular,  and  presents  there- 
fore a  great  resistance  to  sloughing  and  gangrenous 
conditions.  Large  flaps  of  a  lacerated  scalp,  even 
when  extensively  separated  and  almost  cut  off  from 
the  rest  of  the  head,  are  more  prone  to  live  than  to 
die.  A  like  flap  of  skin,  separated  from  other  parts 
of  the  surface,  would  most  probably  perish  ;  but  the 
scalp  has  this  advantage,  that  the  vessels  run  practic- 
ally in  the  skin  itself,  or  are,  at  least,  in  the  tissue 
beyond  the  aponeurosis  (Fig.  1).  Thus,  when  a  scalp 
flap  is  torn  up,  it  still  carries  with  it  a  very  copious 
blood  supply.  Bleeding  from  these  wounds  is  usually 
very  free,  and  often  difficult  to  arrest.     This  depends  not 


Chap,  i.]  The    Scalp.  5 

so  much  upon  the  number  of  vessels  in  the  part  as 
upon  the  density  of  the  tissue  through  which  these 
vessels  run,  the  adherence  of  the  outer  arterial  wall  to 
the  scalp  structure,  and  the  inability,  therefore,  of  the 
artery  to  properly  retract  when  divided. 

For  the  same  reason  it  is  almost  impossible  to  pick 
up  an  artery  divided  in  a  scalp  wound.  The  bleeding 
is  checked  by  a  hare-lip  pin  or  by  pressure. 

In  all  parts  of  the  body  where  a  dense  bone  is 
covered  by  a  comparatively  thin  layer  of  soft  tissues, 
sloughing  of  those  tissues  is  apt  to  be  induced  by  long 
and  severe  pressure.  The  scalp,  by  its  vascularity, 
is  saved  to  a  great  extent  from  this  evil,  and  is  much 
less  liable  to  slough  than  are  the  soft  parts  covering 
such  bones  as  the  condyles  of  the  humerus  or  the  sacrum. 
But  such  an  effect  is  sometimes  produced,  as  in  a  case 
I  saw,  where  the  tissues  over  the  frontal  and  occipital 
regions  sloughed  from  the  continued  application  of  a 
tight  bandage  put  on  to  arrest  bleeding  from  a  frontal 
wound. 

The  pericranium  is  but  slightly  adherent  to  the 
bone,  except  at  the  sutures,  where  it  is  intimately  united 
(Fig.  1,  e).  In  lacerated  wounds  this  membrane  can  be 
readily  stripped  from  the  skull,  and  often,  in  these  injuries, 
extensive  tracts  of  bone  are  laid  bare.  The  pericranium 
differs  somewhat  in  its  functions  from  the  periosteum 
that  covers  other  bones.  If  the  periosteum  be  removed 
to  any  extent  from  a  bone,  the  part  from  whence  it 
is  removed  will  very  probably  perish,  and  necrosis  from 
deficient  blood  supply  result.  But  the  pericranium 
may  be  stripped  off  a  considerable  part  of  the  skull 
vault  without  any  necrosis,  save  perhaps  a  little  super- 
ficial exfoliation,  following  in  consequence.  This  is 
explained  by  the  fact  that  the  cranial  bones  derive  their 
blood  supply  mainly  from  the  dura  mater,  and  are 
therefore  to  a  considerable  extent  independent  of  the 
pericranium.  A  like  independence  cannot  be  claimed 
for  the  periosteum  covering  other  bones,  since  that 
membrane  brings  to  the  part  it  covers  a  very  copious 
and   essential   contribution   to   its   blood   supply.     This 


6  Surgical  Applied  Anatomy.       [Chap.  i. 

disposition  of  the  pericranium  is  also  well  illustrated 
by  its  action  in  cases  of  necrosis  of  the  cranial  bones. 
In  necrosis  of  a  long  bone,  the  separation  of  the  seques- 
trum is  attended  with  a  vigorous  periosteal  growth  of 
new  bone,  which  repairs  the  gap  left  after  the  removal 
of  such  sequestra.  In  necrosis  of  the  vault  of  the  skull, 
however,  no  new  bone  is,  as  a  rule,  formed,  and  the 
gap  remains  unrepaired.  The  general  indisposition  of 
the  pericranium  to  form  new  bone  in  other  cir- 
cumstances is  frequently  illustrated. 

Abscess  in  the  scalp  region  may  be  situated  (1) 
above  the  aponeurosis,  (2)  between  the  aponeurosis 
and  the  pericranium,  and  (3)  beneath  the  pericranium. 
Abscesses  in  the  first  situation  must  always  be  small 
and  comparatively  insignificant,  since  the  density  of 
the  scalp  tissue  here  is  such  that  suppuration  can  only 
extend  with  the  greatest  difficulty.  Suppuration, 
however,  in  the  second  situation  (in  the  loose  tissue 
beneath  the  aponeurosis)  may  prove  very  serious.  The 
laxity  of  this  tissue  offers  every  inducement  to  the 
abscess  to  extend  when  once  pus  has  found  its  way 
between  the  aponeurosis  and  the  pericranium.  Sup- 
puration in  this  area  may  undermine  the  entire  scalp, 
which  in  severe  and  unrelieved  cases  may  rest  upon 
the  abscess  beneath  as  upon  a  kind  of  water-bed.  As 
in  scalp  wounds  the  aponeurosis  is  often  divided,  and 
as  suppuration  may  follow  the  injury,  it  will  be  seen 
that  the  chief  danger  of  those  lesions  depends  upon 
the  spreading  of  such  suppuration  to  the  area  of  lax 
connective  tissue  now  under  notice.  The  significance 
of  a  small  amount  of  bare  bone  in  a  scalp  wound  is  not 
so  much  that  evils  will  happen  to  the  bone,  but  that 
the  aponeurosis  has  been  certainly  divided  and  the 
dangerous  area  of  the  scalp  opened  up.  Suppuration, 
when  it  occurs  in  this  area,  is  only  limited  by  the  attach- 
ments of  the  occipito-frontalis  muscle  and  its  aponeurosis, 
and  therefore  the  most  dependent  places  through  which 
pus  can  be  evacuated  are  along  a  line  drawn  round 
the  head,  commencing  in  front,  above  the  eyebrow, 
passing  at  the  side  a  little  above  the  zygoma,  and  ending 


Chap,  i]  The  Scalp.  7 

behind  at  the  superior  curved  line  of  the  occipital  bone. 
The  scalp,  even  when  extensively  dissected  up  by  such 
abscesses,  does  not  perish,  since  it  carries,  as  above 
explained,  its  blood  supply  with  it.  The  abscess  is 
often  very  slow  to  close,  since  its  walls  are  prevented 
from  obtaining  perfect  rest  by  the  frequent  movement 
of  the  epicranial  muscle.  To  mitigate  this  evil,  and 
to  ensure  closing  of  the  sinuses  in  obstinate  cases,  Mr. 
Hilton  advises  that  the  whole  scalp  be  firmly  secured 
by  strapping,  so  that  the  movement  of  the  muscle  is 
arrested. 

Abscess  beneath  the  pericranium  must  be  limited 
to  one  bone,  since  the  dipping  in  of  the  membrane  at 
the  sutures  prevents  a  more  extensive  spreading  of  the 
suppuration. 

Haematoiiiata,  or  blood  tumours  of  the 
scalp  region,  occur  in  the  same  localities  as  abscess. 
The  extravasation  of  blood  above  the  aponeurosis  must 
be  of  a  limited  character,  while  that  beneath  it  may 
be  very  extensive.  It  fortunately  happens,  however, 
that  the  cellular  tissue  between  the  aponeurosis  and 
the  pericranium  contains  but  very  few  vessels,  and 
hence  large  extravasations  in  this  tissue  are  uncommon. 

Extravasations  of  blood  beneath  the  pericranium 
are  generally  termed  cephalhsematomata,  and  are  of 
necessity  limited  to  one  bone.  They  are  usually  con- 
genital, are  due  to  pressure  upon  the  head  at  birth, 
and  are  thus  most  commonly  found  over  one  parietal 
bone,  that  bone  being  probably  the  one  most  exposed 
to  pressure.  Their  greater  frequency  in  male  children 
may  depend  upon  the  larger  size  of  the  head  in  the 
male  foetus.  Such  extravasations  in  early  life  are 
encouraged  by  the  laxity  of  the  pericranium,  and  by 
the  softness  and  vascularity  of  the  subjacent  bone. 

In  the  temporal  region,  or  the  region  corre- 
sponding to  the  temporal  muscle,  the  layers  of  soft 
parts  between  the  skin  and  the  bone  are  somewhat 
different  from  those  that  have  been  already  described 
as  common  to  the  chief  parts  of  the  scalp.  There  is  a 
good  deal  of  fat  in  the  temporal  fossa,  and  when  this 


8  Surgical  Applied  Anatomy.        [Chap.  i. 

is  absorbed  it  leads  to  more  or  less  prominence  of  tlie 
zygoma  and  malar  bone,  and  so  produces  the  projecting 
"  cheek  bones  "  of  the  emaciated.  The  temporal  muscle 
above  the  zygoma  is  covered  in  by  a  very  dense  fascia, 
the  temporal  fascia,  which  is  attached  above  to  the 
temporal  ridge  on  the  frontal  and  parietal  bones,  and 
below  to  the  zygomatic  arch.  The  unyielding  nature 
of  this  fascia  is  well  illustrated  by  a  case  recorded  by 
Denonvilliers.  It  concerned  a  woman  who  had  fallen 
in  the  street,  and  who  was  admitted  into  hospital  with 
a  deep  wound  in  the  temporal  region.  A  piece  of  bone 
of  several  lines  in  length  was  found  loose  at  the  bottom 
of  the  wound,  and  was  removed.  After  its  removal 
the  ringer  could  be  passed  through  an  opening  with 
an  unyielding  border,  and  came  in  contact  with  some 
soft  substance  beyond.  The  case  was  considered  to  be 
one  of  compound  fracture  of  the  squamous  bone,  with 
separation  of  a  fragment  and  exposure  of  the  brain. 
A  bystander,  however,  noticed  that  the  bone  removed 
was  dry  and  white,  and  a  more  complete  examination 
of  the  wound  revealed  the  fact  that  the  skull  was  un- 
injured, that  the  supposed  hole  in  the  skull  was  merely 
a  laceration  of  the  temporal  fascia,  that  the  soft  matter 
beyond  was  muscle  and  not  brain,  and  that  the  fragment 
removed  was  simply  a  piece  of  bone  which,  lying  on 
the  ground,  had  been  driven  into  the  soft  parts  when 
the  woman  fell. 

Abscesses  in  the  temporal  fossa  are  prevented  by 
the  fascia  from  opening  anywhere  above  the  zygoma, 
and  are  encouraged  rather  to  spread  into  the  pterygoid 
and  maxillary  regions  and  into  the  neck. 

The  pericranium  in  the  temporal  region  is  much 
more  adherent  to  the  bone  than  it  is  over  the  rest  of 
the  vault,  and  subpericranial  extravasations  of  blood 
are  therefore  practically  unknown  in  this  part  of  the 
cranial  wall. 

Trephining?.— This  operation  is  frequently  per- 
formed in  the  temporal  region,  its  object  being  to  reach 
extravasations  of  blood  from  the  middle  meningeal 
artery.     This  artery  crosses  the  anterior  inferior  angle 


Chap.   I.] 


The  Scalp. 


of  the  parietal  bone  at  a  point  \1>  inches  behind  the 
external  angular  process  of  the  frontal  bone,  and  If 
inches  above  the  zygoma. 

In  cutting  down  to  the  bone  in  the  temporal  region 
the  following  ^structures  are  met  with  in  order  :  (1)  The 
skin  ;  (2)  branches  of  the  superficial  temporal  vessels 
and  nerves  ;    (3)  the  fascia  continued  down  from  the 


D 

Fia\  ?.  -Points  for  Tve 'limine-. 

a,  v..  Spots  for  trephining  in  middle  meningeal  haemorrhage  :  c,  spot  for  trephin- 
ing in  abscess  of  the  temporo-sphenoidal  lobe:  d,  mastoid  foramen.  (.After 
Nancrede.) 

epicranial  aponeurosis  ;  (4)  the  temporal  fascia  ;  (5)  the 
temporal  muscle  ;  (6)  the  deep  temporal  vessels  ;  and 
(7)  the  pericranium. 

Trephining  for  meningeal  hcemorrfiage. — Unless 
localising  symptoms  give  other  indications,  Kronlein 
advises  that  the  trephine  holes  in  cases  of  meningeal 
haemorrhage  be  determined  as  follows  : — A  line  is  drawn 
around  the  skull  at  the  level  of  the  upper  margin  of  the 
orbit,  and  is  throughout  parallel  with  Reid's  base-line, 
Fig.  2.  (See  also  page  35.)  The  trephine  is  first  placed 
at  a  point  on  this  line,  which  is  from  l\  to  1|  inches 


io  Surgical  Applied  Anatomy.       [Chap.  i. 

(according  to  age  and  size  of  head)  behind  the  external 
angular  process  of  the  frontal  bone  (Fig.  2,  a).  Should 
no  clot  be  revealed,  a  second  hole  is  made  upon  the  same 
line,  just  below  the  parietal  eminence,  and  at  a  point 
where  a  vertical  line  carried  up  from  the  posterior  border 
of  the  mastoid  process  bisects  the  line  already  given 
(Fig.  2,  b).  The  anterior  branch  of  the  middle  menin- 
geal artery  is  exposed  at  the  first  point,  and  the  posterior 
branch  at  the  second. 

Trephining  for  intracranial  abscess. — The  abscess 
is  often  due  to  middle-ear  disease,  and  is  then  very  com- 
monly found  in  the  temporo-sphenoidal  lobe  or  in  the 
cerebellum.  It  is  estimated  to  be  threee  times  more 
common  in  the  cerebrum  than  in  the  cerebellum. 

The  abscess  of  the  temporo-sphenoidallobe  is  usually 
found,  according  to  Mr.  Barker,  between  two  lines 
drawn  at  right  angles  to  Keid's  base-line.  These  lines 
are  about  1  \  inches  apart ;  one  passes  through  the 
meatus,  the  other  about  \\  inches  behind  that  opening 
(Fig.  2,  xx).  The  trephine  should  be  introduced  in  the 
centre  of  the  space  marked  out  by  these  two  lines,  and 
at  a  distance  of  about  \\  inches  above  the  base-line 
(Fig.  2,  c). 

In  dealing  with  an  abscess  of  the  cerebellum,  the 
best  spot  to  select  is,  in  the  adult,  \\  inches  behind 
the  centre  of  the  meatus  and  a  quarter  of  an  inch  below 
the  base-line  (Fig.  3,  d). 

In  some  cases  it  is  impossible  to  say  if  the  abscess 
is  situated  in  the  temporo-sphenoidal  lobe  or  cerebellum. 
In  such  cases  Mr.  Dean  trephines  at  a  point  which  lies 
\\  inches  behind  and  a  quarter  of  an  inch  above  the 
centre  of  the  meatus.  The  lateral  sinus  is  thus  exposed 
with  a  part  of  the  dura  mater  above  the  tentorium 
cerebelli,  through  which  the  temporo-sphenoidal  lobe 
may  be  explored.  By  extending  the  trephine  opening 
half  an  inch  downwards  the  cerebellum  may  be  examined. 

Trephining  for  cerebral  tumour. — The  position  of 
the  opening  in  the  skull  is  obviously  determined  by 
the  localising  symptoms.  It  is  remarkable  that  little 
trouble  from  haemorrhage  has  attended  these  operations. 


Chap.   I.J 


The  Scalp. 


ii 


In  any  ease,  after  trephining,  the  portion  or  portions 
of  bone  removed  may — if  properly  treated — be  replaced 
in  the  opening,  and  will  serve  to  make  good  the  gap 
left  by  the  operation. 

In  trephining  the  skull  generally,  the  comparative 
thickness  of  the  cranial  wall  in  various  parts  should 
be  borne  in  mind  (page  28),  and  the  large  arteries  of 


Fig.  3.— Posterior  part  of  Skull  showing  Points  for  Trephining. 
{After  Dean.) 

rr,  Reid's  base  line  ;  a,  mental  point  (central  point  of  external  auditory  meatus) ; 
b.  over  sigmoid  smus(|"  behind  mental  point) ;  c,  over  lateral  sinus  (1"  behind 
and  \"  above  mental  point);  d,  over  cerebellum  (lj"  behind  and  J"  below 
nuatal  point);  B,  supra-meatal  triangle,  over  mastoidal  antrum  ;  f,  point 
for  tapping  lateral  ventricle  di" above  nieatalpoint)  ;  a  l,  meato-lambdoidal 
line— the  second  inch  of  this  line  lies  over  the  convexity  of  the  lateral  sinus. 

the  scalp  should  be  avoided  if  possible.  In  order  to 
accommodate  the  instrument  to  the  varying  thickness 
of  the  skull,  the  pin  of  the  trephine  is  not  allowed  to 
protrude  more  than  t^th  of  an  inch.  The  trephine 
should  not  be  applied  over  the  frontal  sinuses,  which 
are  often  of  large  size  in  the  aged,  and  should,  when 
possible,  keep  clear  of  the  sutures,  owing  to  the  frequent 
exit  of  emissary  veins  at  or  about  suture  lines.  The 
bone,  moreover,  at  certain  of  these  lines  is  of  unequal 
thickness.     Between    the    bones    forming    the    sutures 


12  Surgical  Applied  Anatomy.       [Chap.  I. 

passes  the  sutural  membrane.  This  structure  blends 
with  the  dura  mater,  and  laceration  of  it  may  conduce 
to  meningitis.  Especially  must  the  superior  longitud- 
inal sinus  be  avoided,  which  runs  backwards  in  the 
middle  line,  and  terminates  at,  or  slightly  above,  the 
external  occipital  protuberance.  Lateral  lacuna?  of  this 
sinus  may  be  encountered  over  an  inch  distant  from 
the  middle  line.  The  lateral  sinus  begins  at  the  external 
occipital  protuberance,  passes  forwards  and  slightly 
upwards  and  then  bends  downwards  to  groove  the 
mastoid  three  quarters  of  an  inch  behind  the  external 
auditory  meatus.  In  its  passage  forwards  it  rises 
half  an  inch  above  the  level  of  the  meatus.  If  a  line  be 
drawn  from  the  meatal  point  to  the  lambda,  it  will  be 
found  that  the  second  inch  of  this  line,  counting  from 
the  meatus,  lies  over  the  convexity  of  the  lateral  sinus 
{see  Fig.  3).       • 

The  zjgoma  may  be  broken  by  direct  or  indirect 
violence.  In  the  latter  case  the  violence  is  such  as 
tends  to  thrust  the  upper  jaw  or  malar  bone  backwards. 
When  due  to  direct  violence,  a  fragment  may  be  driven 
into  the  temporal  muscle,  and  much  pain  caused  in 
moving  the  jaw.  In  ordinary  cases  there  is  little  or 
no  displacement,  since  to  both  fragments  the  temporal 
fascia  is  attached  above  and  the  masseter  below. 

The  vessels  and  nerves  of  the  scalp.— The 
supraorbital  artery  and  nerve  pass  vertically  upwards 
from  the  supraorbital  notch,  which  is  situate  at  the 
junction  of  the  middle  with  the  inner  third  of  the  upper 
orbital  margin.  Nearer  the  middle  line  the  frontal 
artery  and  supratrochlear  nerve  ascend.  This  artery 
gives  life  to  the  flap  that  in  rhinoplasty  is  taken  from 
the  forehead  to  form  a  new  nose.  The  temporal  artery, 
with  the  auriculo-temporal  nerve  behind  it,  crosses 
the  base  of  the  zygoma  just  in  front  of  the  ear.  The 
vessel  divides  into  its  two  terminal  branches  (the  an- 
terior and  posterior)  2  inches  above  the  zygoma.  The 
branches  of  this  artery,  especially  the  anterior  branch, 
are  often  very  tortuous  in  the  aged,  and  afford  early 
evidence  of  arterial  degeneration.     Arteriotomy  is  some- 


chap,  i.]  The  Scalp.  13 

times  practised  on  the  anterior  branch  of  this  vessel. 
The  superficial  temporal  vessels  are  very  liable  to  be  the 
seat  of  cirsoid  aneurism,  as,  to  a  less  extent,  are  the  other 
scalp  arteries.  Cirsoid  aneurism  is  more  often  met  with 
in  the  superficial  temporal  arteries  than  in  any  other 
artery  in  the  body.  The  posterior  auricular  artery  and 
nerve  run  in  the  groove  between  the  mastoid  process 
and  the  ear,  and  the  occipital  artery  and  great  occipital 
nerve  reach  the  scalp  just  internal  to  a  point  midway  be- 
tween the  occipital  protuberance  and  the  mastoid  process. 

Certain  of  the  emissary  veins  are  of  great  import- 
ance in  surgery.  These  veins  pass  through  apertures 
in  the  cranial  wall,  and  establish  communications  be- 
tween the  venous  circulation  (the  sinuses)  within  the 
skull  and  the  superficial  veins  external  to  it.  The 
principal  emissary  veins  are  the  following  :  1.  A  vein 
passing  through  the  mastoid  foramen  and  connecting 
the  lateral  sinus  with  the  posterior  auricular  vein  or 
with  an  occipital  vein.  This  is  the  largest  and  most 
constant  of  the  series.  The  existence  of  this  mastoid 
vein  serves  to  answer  the  question,  Why  is  it  a  common 
practice  to  apply  leeches  and  blisters  behind  the  ear  in 
certain  cerebral  affections  1  2.  A  vein  connecting  the 
superior  longitudinal  sinus  with  the  veins  of  the  scalp 
through  the  parietal  foramen.  3.  A  vein  connecting 
the  lateral  sinus  with  the  deep  veins  at  the  back  of  the 
neck  through  the  posterior  condylar  foramen  (incon- 
stant). 4.  Minute  veins  following  the  twelfth  nerve 
through  its  foramen,  and  connecting  the  occipital  sinus 
with  the  deep  veins  of  the  neck.  5.  Minute  veins  passing 
through  the  foramen  ovale,  foramen  lacerum  and  carotid 
canal  to  connect  the  cavernous  sinus  with  (respectively) 
the  pterygoid  venous  plexus,  the  pharnygeal  plexus, 
and  the  internal  jugular  vein. 

Then,  again,  many  minute  veins  connect  the  veins 
of  the  scalp  with  those  of  the  diploe.  Of  the  four  diploic 
veins,  two  (the  frontal  and  anterior  temporal)  enter 
into  surface  veins  (the  supraorbital  and  deep  temporal), 
and  two  (the  posterior  temporal  'and  occipital)  enter 
into  the  lateral  sinus. 


14  Surgical  Applied  Anatomy.       [Chap  i. 

Lastly,  there  is  the  well-known  communication 
between  the  extra-  and  intra-cranial  venous  circulation 
effected  by  the  commencement  of  the  facial  vein  at 
the  inner  angle  of  the  orbit.  In  this  communication 
the  angular  and  supraorbital  veins  unite  with  the  super- 
ior ophthalmic  vein,  a  tributary  of  the  cavernous 
sinus. 

Through  these  various  channels,  and  through  many 
probably  still  less  conspicuous,  inflammatory  processes 
can  spread  from  the  surface  to  the  interior  of  the  skull. 
Thus  we  find  such  affections  as  erysipelas  of  the  scalp, 
diffuse  suppuration  of  the  scalp,  necrosis  of  the  cranial 
bones,  and  the  like,  leading  by  extension  to  mischief 
within  the  diploe,  to  thrombosis  of  the  sinuses,  and  to 
inflammation  of  the  meninges  of  the  brain.  If  there 
were  no  emissary  veins,  injuries  and  diseases  of  the 
scalp  and  skull  would  lose  half  their  seriousness.  Mis- 
chief may  even  spread  from  within  outwards  along  an 
emissary  vein.  Erichsen  reports  a  case  where  the 
lateral  sinus  was  exposed  in  a  compound  fracture.  The 
aperture  was  plugged.  Thrombosis  and  suppuration 
within  the  sinus  followed,  and  some  of  the  pus,  escaping 
through  the  mastoid  vein,  led  to  an  abscess  in  the 
neck. 

Certain  venous  tumours  are  met  with  on  the  skull. 
They  consist  of  collections  of  venous  blood  under  the 
pericranium  that  communicate,  through  holes  in  the 
skull,  with  the  superior  longitudinal  sinus.  They  are 
median,  are  reducible  on  pressure,  and  receive  a  faint 
pulsation  from  the  brain.  The  holes  are  sometimes 
the  result  of  accident,  others  depend  upon  bone  disease 
or  atrophy  about  a  Pacchionian  body,  and  a  few  are 
due  to  a  varicose  emissary  vein  or  to  a  congenital  defect 
in  the  cranium. 

The  scalp  nerves,  especially  such  as  are  branches 
of  the  fifth  pair,  are  often  the  seat  of  neuralgia.  To 
relieve  one  form  of  this  affection,  the  supraorbital  nerve 
has  been  divided  (neurotomy)  at  its  point  of  exit  from 
the  orbit,  and  a  portion  of  the  nerve  has  been  resected 
(neurectomy)  in  the  same  situation. 


Chap,  ii.]    Bony   Vault  of  the  Cranium.  15 

Some  forms  of  frontal  headache  depend  upon 
neuralgia  of  this  nerve.  The  inner  branch  of  the  nerve 
reaches  the  middle  of  the  parietal  bone  ;  the  outer 
branch,  the  lambdoid  suture. 

The  lymphatics  from  the  occipital  and  posterior 
parietal  regions  of  the  scalp  enter  the  occipital  and 
mastoid  glands  ;  those  from  the  frontal  and  anterior 
parietal  regions  go  to  the  parotid  glands,  while  some 
of  the  vessels  from  the  frontal  region  join  the  lymphatics 
of  the  face  and  end  in  the  submaxillary  glands  (Fig.  21). 


CHAPTER  II. 

THE  BONY  VAULT  OF  THE  CRANIUM. 

Position  of  the  sutures.— The  bregma,  or 
point  of  junction  of  the  coronal  and  sagittal  sutures, 
is  in  a  line  drawn  vertically  upwards  from  a  point  jugi: 
in  front  of  the  external  auditory  meatus,  the  head 
being  in  normal  position  (Fig.  2).  The  lambda,  or 
point  of  junction  of  the  lambdoid  and  sagittal  sutures, 
lies  in  the  middle  line,  about  2f  inches  above  the  occipital 
protuberance.  The  lambdoid  suture  is  fairly  represented 
by  the  upper  two-thirds  of  a  line  drawn  from  the  lambda 
to  the  apex  of  the  mastoid  process  on  either  side.  The 
coronal  suture  lies  along  a  line  drawn  from  the  bregma 
to  the  middle  of  the  zygomatic  arch.  On  this  line, 
at  a  spot  about  on  a  level  with  the  external  angular 
process  of  the  frontal  bone,  and  about  1^  inches  behind 
that  process,  is  the  pterion,  the  region  where  four  bones 
meet,  viz.  the  squamous  bone,  the  great  wing  of  the 
sphenoid,  the  frontal  and  parietal  bones.  The  summit 
of  the  squamous  suture  is  If  inches  above  the  zygoma. 

In  the  normal  subject  all  traces  of  the  fontanel les 
and  other  unossified  parts  of  the  skull  disappear  before 
the  age  of  two  years.  The  anterior  fontanelle  is  the 
last  to  close,  while  the  posterior  is  already  filled  at  the 
time  of  birth.  It  is  through  or  about  the  anterior 
fontanelle   that   the    ventricles    are     usually   aspirated 


1 6  Surgical  Applied  Anatomy.      [Chap.  ii. 

in  cases  of  hydrocephalus.  The  needle  is  entered  either 
at  the  sides  of  the  fontanelle  at  a  sufficient  distance 
from  the  middle  line  to  avoid  the  sinus,  or  is  introduced 
through  the  coronal  suture  at  some  spot  other  than 
its  middle  point.  It  may  be  noted  that  in  severe  hydro- 
cephalus the  coronal  and  other  sutures  of  the  vault 
;are  widely  opened. 

The  condition  known  as  cranio-tafoes,  a  condition 
'assigned  by  some  to  rickets  and  by  others  to  inherited 
syphilis,  is  usually  met  with  in  the  vertical  part  of  the 
^occipital  bone,  and  in  the  adjacent  parts  of  the  parietal 
•bones,  but  especially  in  the  posterior  inferior  angles 
of  these  bones.  In  this  condition  the  bone  is  greatly 
thinned  in  spots,  and  its  tissue  so  reduced  that  the 
affected  district  feels  to  the  finger  as  if  occupied  by 
parchment,  or,  as  some  suggest,  by  cartridge  paper. 
The  thinning  is  mainly  at  the  expense  of  the  inner 
table  and  diploe.  The  pits  are  situated  in  early  formed 
convolution  impressions.  It  is,  on  the  other  hand, 
about  the  site  of  the  anterior  fontanelle  that  certain 
osseous  deposits  are  met  with  on  the  surface  of  the 
skull  in  some  cases  of  hereditary  syphilis  (Parrot). 
These  deposits  appear  as  rounded  elevations  of  porous 
bone  situated  upon  the  frontal  and  parietal  bones,  where 
they  meet  in  the  middle  line.  These  bosses  are  separated 
by  a  crucial  depression  represented  by  the  frontal  and 
sagittal  sutures  on  the  one  hand  and  the  coronal  suture 
on  the  other.  They  have  been  termed  "  natiform " 
elevations  by  M.  Parrot,  from  their  supposed  resem 
blance,  when  viewed  collectively,  to  the  nates.  To 
the  English  mind  they  would  rather  suggest  the  outlines 
of  a  "  hot-cross  bun." 

It  is  necessary  to  refer  to  the  development  of 
the  skill i  in  order  to  render  intelligible  certain 
conditions  (for  the  most  part  those  of  congenital  mal 
formation)  that  are  not  unfrequently  met  with. 
Speaking  generally,  it  may  be  said  that  the  base  of 
the  skull  is  developed  in  cartilage,  and  the  vault  in 
membrane.  The  parts  actually  formed  in  membrane 
are-  represented  in  the  completed  skull  by  the  frontal 


Chap,  ii.]    Bony  Vault  of  the  Cranium-. 


17 


and  parietal  bones,  the  squamo-zygomatie  part  of  the 
temporal  bone,  and  the  greater  part  of  the  expanded 
portion  of  the  occipital  bone.  The  distinction  between 
these  two  parts  of  the  skull  is  often  rendered  very  marked 
by  disease.  Thus  there  are,  in  the  museum  of  the 
Royal  College  of  Surgeons,  the  skulls  of  some  young- 
lions  that  were  born  in  a  menagerie,  and  that,  in  con- 
sequence of  mal-nutrition,  developed  certain  changes 
in  their  bones.  A  great  part  of  each  of  these  skulls 
shows  considerable  thickening,  the  bone  being  converted 
into  a  porous  structure  ;  and  it  is  remarkable  to  note 
that  these  changes  are  limited  to  such  parts  of  the  skull 
as  are  formed  in  membrane,  the  base  remaining  free. 

Among  the  more  common  of  the  gross  malformations 
of  the  skull  also  is  one  that  shows  entire  absence  of  all 
that  part  of  the  cranium  that  is  formed  in  membrane, 
while  the  base,  or  cartilaginous  part,  is  more  or  less 
perfectly  developed. 

Meningocele  is  the  name  given  to  a  congenital 
tumour  that  consists  of  a  protrusion  of  a  part  of  the 
cerebral  membranes  through  a  gap  in  an  imperfectly 
developed  skull.  When  the  protrusion  contains  brain, 
it  is  called  an  encephalocele,  and 
when  that  protruded  brain  is  dis- 
tended by  an  accumulation  of  fluid 
within  the  ventricles,  it  is  called 
hydrencephalocele.  These  protru- 
sions are  most  often  met  with  in 
the  occipital  bone,  and  next  in  fre- 
quency in  the  fronto-nasal  suture, 
while  in  rarer  cases  they  have 
been  met  with  in  the  lambdoid, 
sagittal,  and  other  sutures,  and 
have  projected  through  normal 
and  abnormal  fissures  at  the  base 
•of  the  skull  into  the  orbit,  nose, 
and  mouth.  Their  frequency  in 
the  occipital  bone  may  be  in  some 
way  explained  by  a  reference  to  the  development  of  that 
part.     This  bone  at  birth  consists  of  four  separate  parts 


Fig.  4.— The  Occpital 
Bona  at  Birth. 


1 8  Surgical  Applied  Anatomy.      [Chap.  n. 

{see  Fig.  4),  a  basilar,  two  condylar,  and  a  tabular  or 
expanded  part.  In  the  tabular  part,  about  the  seventh 
week  of  foetal  life  four  nuclei  appear,  an  upper  and  a  lower 
pair.  These  nuclei  are  to  some  extent  separated  by 
fissures,  running  inwards  from  the  four  angles  of  the 
bone  to  meet  at  the  occipital  protuberance.  The  gap 
running  up  in  the  median  line  from  the  inferior  angle 
at  the  foramen  magnum  to  the  occipital  protuberance 


Fig.  5 —Back  View  of  Abnormal  Skulls,   showing  Occipital  and 

Parietal  Bones. 

a,  The  "  os  epactal  "  ;  n,  parietal  Assures  ;  c,  the  sagittal  fontanelle. 


is  especially  distinct  (the  temporary  occipital  fontanelle 
of  Sutton).  It  exists  from  the  beginning  of  the  third 
to  the  end  of  the  fourth  month  of  intrauterine  life. 
Meningoceles  of  the  occiput  are  always  in  the  middle 
line,  and  the  protrusion  probably  occurs  through  this 
gap.  The  gap  associated  with  meningocele  may  extend 
through  the  whole  vertical  length  of  the  occipital  bone, 
and  very  commonly  opens  up  the  foramen  magnum. 
The  lateral  or  transverse  fissures  divide  the  bone  into 
two  parts.     The  upper  part  is  developed  from  membrane, 


chap,  ii.]    Bony   Vault  of  the  Cranium.  19 

the  lower  part  from  cartilage.  The  lateral  fissures 
may  persist,  and  may  simulate  fractures,  for  which 
they  have,  indeed,  been  mistaken  ;  or  they  may  be  so 
complete  as  to  entirely  separate  the  highest  part  of 
the  occipital  bone  from  the  remainder.  The  bone  so 
separated  is  the  ns  epactal  of  the  French  (Fig.  5,  a),  the 
interparietal  bone  of  some  animals. 

Parietal  fissures.— In  the  developing  parietal 
bone,  fibres  concerned  in  ossification  radiate  towards  the 
periphery  from  two  nuclei  about  the  centre  of  the  bone. 
An  interfibrillar  space,  larger  than  the  rest,  is  seen  about 
the  fifth  month  to  separate  the  loose  osseous  fibres  which 
abut  on  the  posterior  part  of  the  sagittal  border  from  the 
stronger  fibres  which  form  the  rest  of  this  border  (Pozzi). 
This  is  the  parietal  fissure.  It  usually  closes  and  leaves 
no  trace,  but  it  may  persist  in  part  as  a  suture-like 
fissure,  and  be  mistaken  for  a  fracture  (Fig.  5,  b).  If 
the  fissure  persists  equally  on  the  two  sides  an  elong- 
ated lozenge-shaped  gap  is  left,  the  sagittal  fontaneUe. 
It  is  situate  about  an  inch  in  front  of  the  lambda,  and 
occurs  in  over  4  per  cent,  of  newly  born  children  (Lea) 
(Fig.  5,  c).  The  parietal  foramina  are  remains  of  this 
interval. 

Wormian  bones. -These  irregular  bones  may 
be  mistaken  for  fragments  produced  by  fracture.  They 
are  most  usually  met  with  in  the  lambdoid  suture. 
One  Wormian  bone  deserves  special  notice,  as  it  may 
be  met  with  in  trephining  over  the  middle  meningeal 
artery.  It  exists  between  the  anterior  inferior  angle 
of  the  parietal  bone  and  the  great  wing  of  the  sphenoid. 
It  is  scale-like,  and  gives  the  impression  that  the  tip  of 
the  great  wing  had  been  separated.  It  is  known  as 
the  epipteric  bone. 

Necrosis  is  fairly  common  on  the  vault  of  the  skull, 
and  most  often  attacks  the  frontal  and  parietal  bones, 
while,  for  reasons  that  are  not  very  obvious,  it  is  rare 
in  the  occipital  bone.  The  external  table  is  frequently 
necrosed  alone,  it  being  more  exposed  to  injury  and  less 
amply  supplied  with  blood  than  is  the  internal  table. 
From  the  converse  of   these  reasons   it   happens   that 


20  Surgical  Applied  Anatomy.      [Ghap.  11. 

necrosis  of  the  internal  table  alone  is  but  rarely  met 
with.  Necrosis  involving  the  entire  thickness  of  the 
bone  may  prove  very  extensive,  and  in  a  case  reported 
by  Saviard,  practically  the  whole  of  the  cranial  vault 
necrosed  and"  came  away.  The  patient  was  a  woman, 
and  the  primary  cause  of  the  mischief  was  a  fall  upon  the 
head  when  drunk.     (See  page  5.) 

Necrosis  of  the  skull,  as  well  as  caries  of  the  part, 
is  attended  by  certain  special  dangers  that  depend 
upon  the  anatomical  relations  of  the  cranial  bones. 

Thus,  when  the  whole  thickness  of  the  skull  is 
involved  by  disease,  or  when  the  inner  table  is 
especially  attacked,  a  collection  of  pus  may  form 
between  the  dura  mater  and  the  affected  bone,  and 
may  produce  compression  of  the  brain.  When  the 
diploic  tissue  is  implicated,  the  veins  of  that  part  may 
become  thrombosed,  or  m?,y  be  the  seat  of  a  suppurative 
phlebitis.  The  mischief  thus  commenced  may  spread, 
the  great  intracranial  sinuses  may  be  closed  by  throm- 
bus, or  septic  matter  may  be  conveyed  into  the  general 
circulation  and  lead  to  the  development  of  pyaemia. 

Mere  local  extension  may  also  cause  meningitis. 

In  cases  of  necrosis  of  the  external  table  the  growth 
of  granulation  tissue  from  the  exposed  and  vascular 
diploe  plays  a  very  important  part  in  aiding  the  exfolia- 
tion of  the  lamella  of  dead  bone. 

When  bone  disease  leads  to  perforation  of  the  skull, 
the  pulsations  of  the  brain  may  be  visible  through  the 
abnormal  opening. 

Fractures  of  the  skull.— It  is  not  easy  to 
actually  fracture  the  skull  of  a  young  infant.  The  skull 
as  a  whole  at  this  age  is  imperfectly  ossified,  the  sutures 
are  wide,  and  between  the  bones  there  is  much 
cartilage  and  membrane.  Moreover,  the  bones  them- 
selves in  early  life  are  elastic,  and  comparatively  soft 
and  yielding.  If  a  blow  be  inflicted  upon  the  vault 
in  a  young  child  the  most  probable  effect,  so  far  as 
the  bone  itself  is  concerned,  is  an  indenting  or 
bulging  in  of  that  bone  unassociated  with  a  fracture 
in  the  ordinary  sense.     In  this  particular  relation,  the 


Chap,  ii.]    Boxy  Vault  of  the  Cranium.  21 

skull  of  an  infant  is  to  that  of  an  old  man  as  a 
cranium  of  thin  tin  would  be  to  a  cranium  of  strong 
earthenware.  The  yielding  character  of  the  young 
child's  skull  is  well  illustrated  by  the  gross  deformity 
of  the  head  that  certain  Indian  tribes  produce  in  their 
offspring  by  applying  tight  bandages  to  the  part  in 
infancy.  In  the  Royal  College  of  Surgeons  museum 
are  many  skulls  of  "  flat-headed  "  Indians,  that  show 
to  what  an  extreme  this  artificial  deformity  may  be 
carried.  Gueniot  also  asserts  that  much  deformity  of 
the  head  may  be  produced  in  infants  by  the  practice 
of  allowing  them  to  always  lie  upon  one  side  of  the 
body.  Here  the  deforming  agent  is  simply  the  weight 
of  the  brain. 

Even  in  adults  the  skull  is  much  less  brittle  than 
is  commonly  supposed,  and  notions  as  to  the  breaking 
ability  of  the  cranial  bones  derived  from  the  study 
of  the  dried  specimens  are  apt  to  be  erroneous,  During 
life,  a  sharp  knife  properly  directed  may  be  driven 
through  the  cranial  vault  so  as  to  cause  only  a  simple 
perforating  wound  without  splintering,  and  without 
fracture  of  the  bone  beyond  the  puncture.  Such  a 
wound  may  be  as  cleanly  cut  as  a  wound  through  thick 
leather,  and  a  specimen  in  the  London  Hospital  museum 
serves  well  to  illustrate  this.  A  case  reported  in  the 
Lancet  for  1881  affords  a  strange  instance  of  a  knife 
penetrating  the  skull  without  apparently  splintering 
the  bone.  A  man  wishing  to  commit  suicide  placed  the 
point  of  a  dagger  against  the  skull  in  the  upper  frontal 
region,  and  then  drove  it  well  into  the  brain  by  a  blow 
from  a  mallet.  He  expected  to  fall  dead,  and  was  dis- 
appointed to  find  that  no  phenomena  of  interest  developed. 
He  then  drove  the  dagger  farther  in  by  some  dozen 
blows  with  the  mallet,  until  the  blade,  which  was  four 
inches  long,  was  brought  to  a  standstill.  The  dagger 
was  removed  with  great  difficulty,  the  patient  never 
lost  consciousness,  and  recovered  without  a  symptom. 

The  following  anatomical  conditions  tend  to  minimise 
the  effects  of  violence  as  applied  to  the  skull :  The  density 
of   the   scalp   and   its    great    mobility ;   the    dome-like 


22  Surgical  Applied  Anatomy.      [Chap.  n. 

arrangement  of  the  vault ;  the  number  of  the  bones 
that  compose  the  head,  and  the  tendency  of  the  violence 
to  be  broken  up  amongst  the  many  segments  ;  the 
sutures  which  interrupt  the  continuity  of  any  given 
force,  and  the  sutural  membrane,  which  acts  as  a  kind 
of  linear  buffer ;  the  mobility  of  the  head  upon  the 
spine  ;  and  the  elasticity  of  the  cranial  bones  themselves. 

The  skull  is  further  strengthened  by  the  presence 
of  six  buttresses  or  pillars  at  the  junction  of  the  vault 
and  base.  Two  of  these  are  lateral,  the  orbito-sphenoid 
anteriorly  and  the  petro-mastoid  posteriorly,  while  the 
fronto-nasal  and  occipital  strengthen  the  anterior  and 
posterior  ends  of  the  skull. 

In  children  the  membranous  layer  between  the 
sutures  is  of  considerable  thickness,  but,  as  age 
advances,  this  membrane  disappears,  and  the  bones 
tend  to  fuse  together  (synostosis).  The  sutures  begin 
to  be  obliterated  about  the  age  of  forty,  the  change 
commencing  on  the  inner  aspect  of  the  suture,  and 
appearing  first  in  the  sagittal  suture,  then  in  the 
coronal  and  lambdoid,  and  last  in  the  squamous.  The 
synostosis  may  be  complete  by  the  age  of  eighty 
(Tillaux),  and  its  onset  is  said  to  be  coincident  with 
the  cessation  of  increase  in  the  weight  of  the  brain. 
This  latter  assertion  is  supported  by  the  fact  that  it 
appears  earlier  in  the  lower  races  of  mankind.  As 
age  advances,  moreover,  the  skull  bones  become  less 
porous,  and  lose  much  of  their  elasticity.  They  are, 
therefore,  more  readily  fractured  in  the  aged  than  in 
the  young. 

As  a  rule,  in  fracture,  the  entire  thickness  of  the 
bone  is  involved ;  but  the  external  table  alone  may  be 
broken,  and  may  even  be  alone  depressed,  being"Mriven 
into  the  diploe,  or,  in  the  case  of  the  lower  frontal  region, 
into  the  frontal  sinus.  The  internal  table  may  be  broken 
without  a  corresponding  fracture  in  the  outer  plate  ; 
and  in  nearly  all  cases  of  complete  fracture,  especially 
in  such  as  are  attended  with  depression,  the  internal 
table  shows  more  extensive  splintering  than  does^the 
external.     There  are  many  reasons  for  this.     The\in- 


chap,  ii.]    Boxy   Vault  of  the  Cranium.  23 

ternal  plate  is  not  only  thinner  than  the  external,  but 
is  so  much  more  brittle  as  to  receive  the  name  of  the 
"  vitreous  table."  A  force  applied  to  the  external  table 
may  be  extremely  limited,  and  produce,  as  in  a  sabre 
cut,  but  a  limited  lesion.     As  the  force,  however,  travels 


through  the  diploe  it  becomes  broken  up,  and  reaches 
the  inner  plate  as  a  much  more  diffused  form  of  violence. 
This  is  especially  the  case  when  parts  of  the  outer  table 
are  driven  in.  Then,  again,  the  internal  plate  is  a  part 
of  a  smaller  curve  than  is  the  external  plate  ;    and, 


lastly,  Agne w  assigns  a  reason  for  the  greater  vulner- 
ability of  the  inner  plate  that  has  reference  to  the  general 
yielding  of  the  bone.  In  Fig.  6  a  b  represents  a  section 
of  a  part  of  the  vault  through  both  tables,  and  c  d  and 
two  vertical  and  parallel  lines.     Now,   if  force  be 


EF 


applied  to  the  vault  between  these  parallel  lines,  the 
ends  of  the  arch,  ab,  will  tend  to  become  separated. 


.24  Surgical  Applied  Anatomy      [Chap.  if. 

:  and  the  whole  arch,  yielding,  will  tend  to  assume  the 
i  curve  shown  in  Fig.  7.  In  such  case,  the  lines  c  d 
.and  ef  will  converge  above  and  diverge  below  (Fig.  7), 
:  so  that  the  violence  would  tend  to  force  the  bone  particles 
together  at  the  outer  table  and  asunder  at  the  inner 
\  table. 

Fractures  of  the  vault  are  due  to  direct 
violence.  The  construction  of  the  skull  is  such  that  the 
(fracturing  force  is  resisted  in  many  ways.  (1)  When  a 
blow  is  received  on  the  vertex  in  the  parietal  region,  the 
•force  tends  to  drive  the  upper  borders  of  the  two  parietal 
ibones  inwards.  Such  driving  in  of  these  borders  must 
ibe  associated  with  a  corresponding  outward  movement 
<  of  the  inferior  borders.  This  latter  movement  is  forcibly 
i  resisted  by  the  squamous  bone  and  the  great  wing  of 
the  sphenoid,  which  overlap  the  lower  edge  of  the  parietal 
bone.  Moreover,  the  force  transmitted  to  the  squamous 
bone  is  passed  on  to  the  zygomatic  arch,  which  takes 
its  support  from  the  superior  maxillary  and  frontal 
bone.  This  arch  then  acts  as  a  second  resisting  buttress, 
and  this  transmission  of  force  from  the  vertex  to  the 
facial  bones  is  said  to  be  illustrated  by  the  pain  often  felt 
in  the  face  after  blows  upon  the  top  of  the  head.  (2) 
If  the  upper  part  of  the  frontal  bone  be  struck,  the 
force  is  at  once  transmitted  to  the  parietal  bones,  be- 
cause the  upper  part  of  the  frontal  bone  (owing  to  the 
manner  in  which  its  border  is  bevelled)  actually  rests 
upon  the  two  parietal  bones,  so  the  same  resistance  is 
again  called  into  action.  If  there  be  any  tendency 
for  the  inferior  parts  of  the  bone  to  move  outwards, 
as  would  certainly  be  the  case  while  the  mid-frontal 
suture  existed,  such  movement  would  be  resisted  by  the 
great  wings  of  the  sphenoid  and  by  the  anterior  inferior 
angles  of  the  parietal  bones  which  embrace  or  overlap 
these  parts  of  the  frontal.  Thus  it  will  be  seen 
that  much  depends  upon  the  manner  in  which  the 
corresponding  edges  of  the  frontal  and  parietal  bones 
are  bevelled.  (3)  Blows  upon  the  occiput  are  less  dis- 
tinctly provided  for,  and  it  must  be  owned  that  a  by 
no  means  heavy  fall   is   sufficient   to   break  this  bone. 


Chap,  ii.]    Bony  Vault  of  the   Cranium.  25 

It  must  receive,  however,  much  protection  from  its 
connections  with  the  two  parietal  and  temporal  hones, 
and  from  its  articulation  with  the  elastic  vertehral 
column. 

Fractures  of  the  !>asc  of  the  skull  may  be 
due  to  (1)  direct  or  to  (2)  indirect  violence,  and,  most 
commonly  of  all,  to  (3)  extension  of  a  fracture  from 
the  vault.  (1)  The  base  has  been  fractured  by  direct 
violence  by  foreign  bodies  thrust  through  the  nasal 
roof,  through  the  orbital  roof,  and  through  the  base 
as  it  presents  in  the  pharynx.  The  posterior  fossa  can 
also  be  fractured  by  violence  applied  to  the  nape  of  the 
neck.  (2)  Of  fractures  by  indirect  violence  the  following 
examples  may  be  given  :  Blows  applied  to  the  lower  part 
of  the  frontal  bone  have  been  associated  with  no  lesion 
other  than  a  fracture  of  the  cribriform  plate  or  of  the 
orbital  part  of  the  frontal,  these  parts  being  much 
disposed  to  fracture  on  account  of  their  extreme  tenuity. 
In  falls  upon  the  chin,  the  condyle  of  the  lower  jaw  has 
been  so  violently  driven  against  the  glenoid  cavity  as  to 
fracture  the  middle  fossa  of  the  skull.  Chassaignac 
gives  a  case  where  the  condyle  was  actually  thrust  into 
the  cranial  cavity,  and  produced  an  abscess  in  the  super- 
imposed part  of  the  brain.  When  the  body  in  falling 
has  alighted  upon  the  feet,  knees,  or  buttocks,  the  force 
has  been  transmitted  along  the  vertebral  column,  and 
has  led  to  fracture  of  the  base  in  the  occipital  region. 
Such  accidents  are  most  apt  to  occur  when  the  spine  is 
kept  rigid  by  muscular  action,  and  the  mechanism 
involved  is  precisely  similar  to  that  whereby  the  head  of 
a  broom  is  driven  more  firmly  on  to  the  broom-handle 
by  striking  the  extreme  end  of  the  stick  against  the 
ground.  The  theory  that  the  base  is  often  broken  by 
contre-coup  is  pretty  generally  abandoned,  although 
there  are  a  few  cases  that  appear  to  support  the  sugges- 
tion. Such  a  case  was  recorded  by  Mr.  Hutchinson, 
and  in  it  a  fracture  of  the  occipital  bone  was  associated 
with  a  like  lesion  in  the  cribriform  plate,  the  intervening 
part  of  the  skull  being  uninjured.  (3)  Fractures  of  the 
vault,  and  especially  linear  fractures  due  to  such  diffused 


26  Surgical  Applied  Anatomy.      [Chap.  ii. 

violence  as  obtains  in  a  fall  upon  the  head,  are  very  apt 
to  spread  to  the  base.  In  so  spreading  they  reach  the 
base  by  the  shortest  possible  route,  and  without  any 
regard  to  the  sutures  encountered  or  to  the  density 
of  the  bones  involved.  Thus,  fractures  of  the  frontal 
region  of  the  vault  spread  to  the  anterior  fossa  of  the 
base,  those  of  the  parietal  region  to  the  middle  fossa, 
and  those  of  the  occipital  region  to  the  posterior  fossa. 
To  this  rule  there  are  but  few  exceptions.  To  indicate 
more  precisely  the  exact  bones  involved  in  these  three 
districts,  P.  Hewett  has  divided  the  skull  into  three 
zones.  The  anterior  zone  included  the  frontal,  the 
upper  part  of  the  ethmoid,  and  the  fronto-sphenoid  ; 
the  middle,  the  parietals,  the  squamous,  the  anterior 
part  of  the  petrous  portion,  and  the  greater  part  of  the 
basi-sphenoid ;  and  the  posterior,  the  occipital,  the 
mastoid,  the  posterior  part  of  the  petrous  bone,  with  a 
small  part  of  the  body  of  the  sphenoid. 

In  all  fractures  of  the  base  there  is  usually  a  dis- 
charge of  blood  and  of  cerebro-spinal  fluid  externally. 
(1)  In  fractures  of  the  anterior  fossa  the  blood  usually 
escapes  from  the  nose,  and  is  derived  from  \h&  menin- 
geal vessels,  or  in  greater  degree  probably  from  the 
torn  mucous  lining  of  the  nasal  roof.  To  allow  of  the 
escape  of  cerebro-spinal  fluid  from  the  nose,  there  must 
be,  in  addition  to  the  fracture  in  the  nasal  roof, 
a  laceration  of  the  mucous  membrane  below  that 
fracture,  and  of  the  dura  mater  and  arachnoid  above 
it.  In  many  cases  of  fracture  in  this  part  the  blood 
finds  its  way  into  the  orbit,  and  appears  beneath  the 
conjunctiva.  (2)  When  the  middle  fossa  is  involved, 
the  blood  escapes  from  the  external  auditory  meatus, 
through  a  rupture  in  the  tympanic  membrane,  and  is 
derived  from  the  vessels  of  the  tympanum  and  its  mem- 
brane, or  from  an  intracranial  extravasation,  and  in 
some  cases  from  a  rupture  of  one  of  the  sinuses  about 
the  petrous  bone.  The  blood  may  follow  the  Eustachian 
tube,  and  may  escape  from  the  nose  or  mouth,  or  be 
swallowed  and  subsequently  vomited.  To  allow  of_ 
the  escape  of  cerebro-spinal  fluid  by  the  ear  ("  the  serous 


chap,  ii.]    Bony  Vault  of  the  Cranium.  27 

discharge  "),  (a)  the  fracture  must  have  passed  across 
the  internal  auditory  meatus ;  (b)  the  tubular  pro- 
longation of  the  membranes  in  that  meatus  must  have 
been  torn  ;  (c)  there  must  be  a  communication  between 
the  internal  ear  and  the  tympanum ;  and  (d)  the 
membrana  tympani  must  have  been  lacerated.  (3) 
In  fractures  of  the  posterior  fossa  an  extravasation  of 
blood  may  appear  about  the  mastoid  process  or  at  the  nape 
of  the  neck,  or  may  even  extend  into  the  cervical  region. 

It  may  be  added  that  in  compound  fractures  of  the 
vault  associated  with  tearing  of  the  dura  mater  and 
arachnoid,  an  escape  of  cerebro-spinal  fluid  has  in  a 
few  rare  instances  been  noted.  After  simple  fracture 
of  the  vault  in  children  a  swelling  may  form  at  the 
injured  part,  which  fluctuates,  becomes  tenser  when 
the  patient  cries,  and  may  possibly  pulsate  synchronously 
with  the  brain.  Such  swellings  are  due  to  a  collection 
of  cerebro-spinal  fluid  beneath  the  scalp,  and  indicate 
a  coincident  rupture  of  the  brain  membranes.  In 
cases  of  free  serous  discharge  from  the  ear  after  injury 
to  the  head,  but  without  fracture,  the  fluid  is  derived 
from  the  mastoid  cells,  and  escapes  through  a  rupture 
in  the  tympanic  membrane.  In  a  few  instances  it  may 
possibly  be  blood  serum,  or  depend  upon  mild  catarrh 
of  the  meatus.  Some  authors  assert  that  it  may  be 
due  to  the  escape  of  the  liquor  Cotunnii,  but  the  very 
minute  quantity  of  that  fluid  in  the  ear  renders  the 
suggestion  improbable. 

Separation  of  sutures.— This  condition,  as  the 
result  of  injury,  is  practically  restricted  to  the  young 
skull.  In  later  life,  force  applied  at  the  site  of  an 
obliterated  suture  may  cause  a  fracture,  which  accu- 
rately follows  the  old  suture  line.  Separation  of  the 
sutures,  independent  of  fracture,  is  very  rare  in  the 
adult  skull.  In  the  few  instances  of  such  a  condition 
the  temporal  bone  has  usually  been  the  one  displaced 
and  the  separation  noted  at  the  squamous  suture.  When 
associated  with  fracture,  the  coronal  and  sagittal  sutures 
are  those  most  frequently  separated,  and  next  in  fre- 
quency the  lambdoid. 


28  Surgical  Applied  Anatomy.      [Chap,  n. 

The  thickness  of  the  skull  cap  varies  greatly, 
not  only  in  different  parts  of  the  same  skull,  but  also 
in  corresponding  parts  in  different  individuals.  The 
average  thickness  is  one  fifth  of  an  inch.  The  thickest 
parts  are  at  the  occipital  protuberance  (where  the  section 
may  measure  half  an  inch),  the  mastoid  process,  and 
the  lower  part  of  the  frontal  bone.  The  bone  over  the 
inferior  occipital  fossae  is  very  thin,  while  it  is  thinnest 
over  the  squamous  bone.  Here  the  bone  may  be  no 
thicker  in  parts  than  a  visiting  card.  The  skull  is  also 
thinned  over  the  sinuses  and  grooves  for  the  meningeal 
vessels.  It  is  especially  thin  over  the  anterior  inferior 
angle  of  the  parietal  bone.  It  is  important  to  remember 
in  trephining  that  the  inner  table  is  not  always  parallel 
with  the  outer. 

Craniectomy.— -This  operation  is  carried  out  in 
cases  of  microcephaly  in  infants  and  children.  It  con- 
sists in  the  removal  of  a  strip  of  bone  from  the  vertex 
of  the  skull  so  as  to  give  to  the  brain,  as  an  American 
author  expresses  it,  "  more  elbow  room." 


CHAPTER    III, 

THE    CEANIAL    CONTENTS. 

The  membranes  of  the  brain.— The  dura 
mater,  from  its  toughness,  forms  an  excellent  protection 
to  the  brain.  It  is  very  intimately  adherent  to  the  bone 
over  the  whole  of  the  base  of  the  skull,  and  consequently 
in  this  situation  extravasations  between  the  membrane 
and  the  bone  are  scarcely  possible.  Over  the  vault  its 
attachments  are  comparatively  loose,  although  it  is  more 
closely  adherent  along  the  lines  of  the  sutures.  This  lax 
attachment  allows  large  hsemorrhagic  and  purulent 
extravasations  to  collect  between  the  dura  mater  and  the 
bone.  S  uch  extravasations  usually  lead  to  compression  of 
the  brain,  and  it  may  be  noted  that  in  the  great  majority 
of  all  cases  of  compression  the  compressing  force  is  out- 
side the  dura  mater.     Thus,   in   uncomplicated  cases 


Chap,  in.]         The  Cranial   Contents.  29 

when  symptoms  of  compression  come  on  at  the  time  of 
an  accident,  the  cause  is  probably  depressed  bone  ;  when 
they  appear  after  a  short  interval,  the  cause  is  probably 
extravasated  blood  between  the  membrane  and  the  bone  ; 
and  when  a  long  interval  (days  or  weeks)  has  elapsed 
after  the  accident,  the  cause  is  probably  a  collection 
of  pus  in  the  same  situation. 

Sir  C.  Bell  pointed  out  that  the  dura  mater  of  the 
vault  may  be  separated  from  the  bone  by  the  vibration 
produced  by  a  blow.  "  Strike  the  skull  of  a  subject 
with  a  heavy  mallet ;  on  dissecting  you  find  the  dura 
mater  to  be  shaken  from  the  skull  at  the  point  struck. 
Repeat  the  experiment  on  another  subject,  and  inject 
the  head  minutely  with  size  injection,  and  you  will 
find  a  clot  of  injection  lying  betwixt  the  skull  and  dura 
mater  at  the  part  struck,  and  having  an  exact  resem- 
blance to  the  coagulum  found  after  violent  blows  on  the 
head."  Tillaux  has  demonstrated  that  the  adhesions 
between  the  dura  mater  and  the  bone  are  particularly 
weak  in  the  temporal  fossa?,  the  most  usual  site  of 
meningeal  haemorrhage. 

When  blood  is  poured  out  between  the  dura  mater 
and  the  bone  in  cases  of  fracture,  the  vessel  that  as  a 
rule  gives  way  is  the  middle  meningeal  artery. 
In  thirty-one  cases  of  such  haemorrhage,  this  vessel  was 
the  source  of  the  bleeding  in  twenty-seven  instances 
(P.  HewTett).  The  vessel,  having  passed  through  the 
foramen  spinosum,  divides  into  two  branches ;  the 
anterior,  the  larger,  runs  upwards  across  the  anterior 
inferior  angle  of  the  parietal  bone  and  ascends  the  vault 
some  distance  behind  the  coronal  suture  ;  the  posterior 
runs  backwards,  with  a  horizontal  sweep  across  the 
squamous  bone,  and  takes  the  course  of  the  second  tem- 
pjral  convolution.     (See  page  9.) 

Mr.  Jacobson  has  shown  that  the  branches  of  the 
artery  are  more  frequently  ruptured  than  the  trunk. 
The  vessel  is  very  frequently  torn  as  it  crosses  the  an- 
terior angle  of  the  parietal  bone.  There  are  many 
reasons  for  this  :  the  bone  where  grooved  by  the  artery 
is  very  thin  ;    the  artery  is  often  so  embedded  in  the 


30  Surgical  Applied  Anatomy.     [Chap.  in. 

bone  that  fracture  without  laceration  of  the  vessel  would 
hardly  be  possible ;  and  lastly,  the  particular  region 
of  the  artery  is  a  part  of  the  skull  peculiarly  liable  to  be 
fractured.  Mr.  Jacobson  shows  that  the  artery  may  be 
ruptured  by  a  force  that  does  not  fracture  the  skull, 
but  merely  leads  to  detachment  of  the  dura  mater. 
{See  page  29.)  Failing  this  vessel,  the  most  frequent 
source  of  extra-meningeal  haemorrhage  is  the  lateral 
sinus,  for  reasons  that  will  be  obvious. 

With  regard  to  the  blood  sinuses  formed  by  the 
dura  mater,  nothing  remains  to  be  added  to  what  has 
been  already  said  (page  12),  except,  perhaps,  to  observe 
that  the  relations  between  the  internal  carotid  artery 
and  cavernous  sinus  are  so  intimate  that  arterio-venous 
aneurism  has  followed  injury  involving  these  parts. 
It  will  be  seen  also  with  what  ease  this  sinus  could  be- 
come thrombosed  in  cases  of  inflammation  within  the 
orbit  by  the  extension  of  the  mischief  along  its  great 
tributaries,  the  two  ophthalmic  veins. 

Sarcomatous  growths,  springing  from  the  dura 
mater  or  other  of  the  meninges,  may  make  their  way 
through  the  cranial  bones,  and  project  as  pulsating 
tumours  beneath  the  scalp.  Such  growths  are  included 
under  the  title  of  "  fungus  of  the  dura  mater." 

Between  the  dura  mater  and  the  arachnoid  is  the 
subdural  space,  formerly  known  as  the  "  cavity  of 
arachnoid"  (Fig.  1,  p.  2).  According  to  Prescott  Hewett, 
extravasations  of  blood  after  injury  are  more  common 
in  this  space  than  in  any  other  part  within  the  skull. 
The  blood  so  poured  out  may  become  more  or  less  dis- 
coloured, and  present  in  time  the  aspect  of  a  thin  and 
peculiar  membrane  ;  or  the  collection  may  form  itself 
into  a  species  of  cyst  ("  arachnoid  cyst ")  that  was  for 
some  time  a  source  of  much  confusion  to  pathologists. 

The  subdural  space  contains  a  small  amount  of 
fluid,  and  acts,  probably,  like  the  pleural  and  peritoneal 
sacs  in  preventing  the  effects  of  friction  during  the 
movements  of  the  brain. 

The  subarachnoid  space  is  between  the  arach- 
noid and  the  pia  mater,  and  it  is  here  that  the  chief 


chap,  in.]         The  Cranial   Contents.  31 

part  of  the  cerebrospinal  fluid  is  lodged.  This  space 
is  larger  in  some  places  than  in  others.  It  is  insignificant 
over  the  convexity  of  the  brain,  but  is  very  extensive 
at  the  base  of  the  skull  in  the  parts  beneath  the  cere- 
bellum, the  medulla,  the  pons,  and  the  interpeduncular 
space  as  far  forwards  as  the  optic  nerves.  Thus  these 
very  important  parts  of  the  brain  do  not  rest  upon 
bone,  but  rest  rather  on  the  subarachnoid  collection 
of  fluid  as  upon  a  water-bed,  to  use  a  comparison  of 
Mr.  Hilton's.  The  only  part  of  the  base  of  the  brain 
that  rests  directly  upon  bone  is  that  part  in  contact 
with  the  orbital  plates  and  lesser  wings  of  the  sphenoid. 
The  posterior  two-thirds  of  the  brain  rests,  upon  the 
"  water-bed,"  and  is  thus  admirably  protected. 

It  is  well  known  that  the  brain  may  be  damaged 
by  contre-coup.  That  is  to  say,  if  the  head  be  struck 
at  one  particular  part,  the  brain  may  be  found  uninjured 
at  the  spot  struck,  but  damaged  at  a  corresponding 
place  on  the  opposite  side  of  the  skull.  The  cerebro- 
spinal fluid  is  much  concerned  in  modifying  the  effects 
of  contre-coup.  Thus,  if  the  vertex  be  struck,  the 
important  structures  at  the  base  of  the  brain  would 
be  in  the  greatest  danger  of  being  severely  injured, 
did  they  lie  in  actual  contact  with  the  bone.  Moreover, 
when  a  blow  falls  upon  the  occiput,  there  may  be  no 
damage  to  the  brain  beneath  the  spot  struck,  but  the 
yielding  mass  is  thrown  forward  within  the  skull,  and 
were  it  not  for  the  "  water-bed,"  the  under  parts  of  the 
cerebrum  would  be  torn  against  the  many  projections 
in  the  base  of  the  skull.  These  projections,  which  are 
so  conspicuous  in  the  dry  skull,  are  moulded  off  in  the 
living  by  the  dura  mater,  and  also  by  the  blood  sinuses 
which  occupy  the  hollows  about  these  projections,  and 
also  certain  margins  of  bone.  As  it  is,  the  only  part 
that  usually  suffers  is  the  under  surface  of  the  frontal 
lobe  (a  comparatively  unimportant  segment),  which, 
being  brought  violently  in  contact  with  the  irregular 
orbital  plate,  is  readily  contused. 

The    subarachnoid    space    communicates    with    the 
ventricles    through    the    foramen    of    Majendie.     This 


o* 


Surgical  Atplied  Anatomy.     [Chap,  ill 


foramen  leads  into  the  fourth  ventricle,  and  is  an  aper- 
ture in  the  pia  mater  that  closes  in  that  ventricle.  From 
the  fourth  ventricle  fluid  can  pass  along  the  iter  into 
the  third  ventricle,  and  from  thence  to  the  lateral 
ventricles  by  the  foramen  of  Monro. 

The  cerebro-spinal  fluid  prevents  the  ill  effects  that 
irregularities  in  the  blood  circulation  might  have  upon 
the  brain,  situate  as  it  is  within  an  unyielding  cavity. 
If  the  great  nerve  centres  in  the  lateral  ventricles  are 
swollen  by  congestion,  they  are  not  met  by  an  unyielding 
wall,  but  merely  displace  some  of  the  cerebro-spinal 
fluid  through  the  foramen  of  Majendie,  until  such  time 
as  their  circulation  is  normal  again. 

Hilton  has  shown  that  closure  of  this  foramen  may 
lead  to  that  excessive  accumulation  of  fluid  within  the 
ventricles  known  as  hydrocephalus.  The  fluid  also 
drains  into  the  veins  of  Galen,  hence  pressure  on  these 
may  bring  about  a  like  result.  It  has  been  proposed 
to  relieve  the  pressure  within  the  lateral  ventricles  in 
cases  of  hydrocephalus  by  draining  the  cerebro-spinal 
fluid  into  the  subdural  space.  It  is  absorbed  at  any 
pressure  above  that  within  the  cerebral  veins  (Hill).  If 
the  brain,  too,  becomes  enlarged  by  congestion,  it  is 
not  met  by  unyielding  bone,  but  rather  by  an  adjustable 
water-bed,  and  during  its  period  of  enlargement  it  merely 
displaces  into  the  spinal  part  of  the  subarachnoid  space 
some  of  the  fluid  that  surrounds  it.  This  mutual  effect 
is  well  illustrated  in  a  case  reported  by  Hilton  of  a  man 
with  a  fracture  of  the  base,  from  whose  ear  cerebro- 
spinal fluid  was  escaping.  The  discharge  of  this 
fluid  was  at  once  greatly  increased  by  expiratory  efforts 
when  the  nose  and  mouth  were  held  closed,  and  the 
veins  compressed  in  the  neck.  The  subarachnoid  space 
is  most  easily  tapped  by  a  lumbar  puncture  {see  p.  548). 

The  surface  relationships  of  the  brain  {see 
Figs.  8  and  9). — The  longitudinal  fissure  of  the  brain 
is  indicated  by  a  line  drawn  along  the  vertex  from 
the  glabella  to  the  external  occipital  protuberance.  It 
is  narrow  in  front,  but  as  it  contains  the  longitudinal 
sinus,  which  rapidly  enlarges  as  it  passes  backwards, 


Chap,  in.] 


The  Cranial   Contents. 


33 


it  becomes  of  considerable  breadth  behind,  and  as  a 
rule  lies  somewhat  towards  the  right  of  the  median 
line,  owing  to  the   predominance  of  the  left  cerebral 


ROLANDO 


BR. 


NASION. 


inion.-X:-.-, 


Fig.  S. — Showing  the  Relation  of  the  Brain  and  Sensori-niotor  Areas  of 
Cortex  to  the  Skull.    {Modified  from  Quain.) 

dr.,  Bregma— at  the  junction  <>£  coronal  and  sagittal  sutures ;  la.,  lambda— at  the 
junction  of  lanibdoidal  and  sagittal  sutures  ;  x.  position  of  parietal  eminence. 
The  sensori-niotor  areas  are  shaded  :  the  leg  and  trunk  areas  with  vertical 
lines;  the  arm  and  hand  areas  with  lines  slanting  forwards;  the  face  and 
mouth  areas  with  lines  slanting  backwards  ;  the  tongue,  pharynx,  and  larynx 
areas  are  stippled.  The  motor  centre  for  speech  on  Broca's  convolution  is 
shaded  with  horizontal  lines.  The  ''word-hearing"  centre  is  indicated  on  the 
superior  temporal  convolution,  and  that  for  the  "word-seeing"  centre  on  the 
angular  convolution.  The  area  shaded  with  horizontal  lines  on  the  posterior 
parts  of  the  middle  and  inferior  frontal  convolutions  is  the  centre  for  com- 
bined movements  of  the  head  and  eyes. 

hemisphere.  Between  the  external  occipital  pro- 
tuberance and  the  ear,  the  lateral  sinus  bounds  the 
lower  level  of  the  cerebrum  and  the  upper  of  the 
cerebellum.  A  line  drawn  from  the  external  occipital 
protuberance   to    the  upper   margin   of    the    external 


34 


Surgical  Applied  Anatomy.     [Chap, in. 


auditory  meatus  indicates  fairly  the  position  of  the 
sinus,  yet  it  must  be  remembered  that  just  behind  the 
ear  its  convexity  passes  above  the  level  of  this  line.  In 
front  of  the  ear  the  upper  border  of  the  zygoma  in  its 
posterior  two-thirds  marks  the  lower  border  of  the 
temporal  lobe.  The  pole  of  the  temporal  lobe  is  f  of 
an  inch  behind  the  outer  margin  of  the  orbit.  On 
the  forehead  a  line  drawn  behind  the  external  angular 
process  and  above  the  eyebrows  to  the  glabella  indicates 
the  lower  level  of  the  frontal  lobe. 


•  iOLANDO 


MID  POiN 


BREGMA . 


INION 


Pig.  9.— Showing  the  Lines  which  indicate  the  Position  of  the  Principal 
Fissures  of  the  Brain. 

m.p.,  Meatal  point— the  centre  of  the  external  auditory  meatus;  iNioy,  over 
external  occipital  protuberance  ;  t,\m.,  lambda  :  p.o.f.,  parietooccipital 
fissure;  x  on  fronto-malar  suture  at  external  angular  process  ;  n.s.,  lateral 
siuus,  crossing  the  posterior  inferior  angle  of  parietal. -.-(See  also  Fig.  3^P- 11.) 


chap,  in.]         The   Cranial   Contents.  35 

The  cerebellum  is  best  explored  at  a  point  \\  inches 
behind  and  \  of  an  inch  below  the  level  of  the  external 
auditory  meatus  {see  Fig.  3,  p.  11).  It  is  deeply  placed, 
being  covered  by  the  insertions  of  the  occipital  muscles. 

Of  the  many  methods  which  have  been  suggested 
for  marking  out  the  fissure  of  Rolando,  the  most 
simple  and  accurate  is  the  following  : — A  point  over 
the  sagittal  suture  is  taken  midway  between  the  glabella 
and  external  occipital  protuberance.  Half  an  inch  behind 
the  mid  point  terminates  the  upper  end  of  the  Fissure 
{see  Fig.  9).  A  line  3^  inches  long  drawn  downwards 
and  forwards  from  this  point,  at  an  angle  of  67°  to  the 
line  of  the  sagittal  suture,  will  indicate  the  position  of 
the  fissure  of  Rolando  in  the  adult.  In  the  child  the 
fissure  is  shorter  and  the  contained  angle  is  5°  smaller. 
The  angle  is  easily  obtained  by  folding  twice  the  corner 
of  a  square  piece  of  paper  at,  and  removing  a  fourth  of,  the 
right  angle.  This  line  may  lie  not  exactly  over  the  fissure, 
for  it  varies  somewhat  in  position  according  to  the 
shape  of  head.  The  sensori-motor  areas  of  the  brain 
are  mostly  represented  in  the  ascending  frontal  and 
parietal  convolutions  which  bound  the  fissure  of  Rolando. 
The  average  width  of  each  of  these  convolutions  is  f  of 
an  inch.  The  coronal  suture  is  about  2  inches  in  front 
of  the  fissure  of  Rolando  at  its  upper  part  and  1\ 
inches  at  its  lower. 

The  fissure  of  Sylvius  is  indicated  thus  :— 
A  point  is  taken  1  \  inches  behind  and  \  of  an  inch  above 
the  most  prominent  point  of  the  external  angular 
process  {see  Fig.  9).  This  point  on  the  temple  overlies 
the  anterior  inferior  angle  of  the  parietal  bone — the 
pterion.  The  pterion  marks  the  junction  of  the  three 
limbs  of  the  fissure  of  Sylvius  with  its  stem.  A  line 
drawn  backwards  and  upwards  from  the  pterion  to  a 
point  f  of  an  inch  below  the  parietal  eminence  indicates 
the  situation^  of  the  posterior  horizontal  limb  or  ramus 
(Fig.  9).  This  ramus  is  bounded  below  by  the  superior 
temporal  convolution,  which  contains  in  its  middle  third 
the  "  word-hearing  "  centre  (Fig.  8).  Above,  it  is  bounded 
from  before  backwards  by  the  basilar  part  of  the  inferior 


$6  Surgical  Applied  Anatomy.     [Cbap.  in. 

frontal  convolution,  the  lower  ends  of  the  ascending 
frontal  and  parietal  convolutions,  and  the  supramarginal 
gyrus.  In  the  three  parts  first  named  are  situated  centres 
for  movements  of  the  tongue,  larynx,  pharynx  and  mouth. 
A  penny  piece  placed  directly  behind  the  termination 
of  the  Sylvian  line  will  cover  the  angular  convolution 
in  which  the  "  word-seeing  "  centre  is  placed  (Fig.  8). 
The  parietal  eminence  covers  the  supramarginal  con- 
volution. The  ascending  limb  of  the  fissure  of  Sylvius 
is  indicated  by  a  line  §  of  an  inch  long  drawn  upwards 
and  slightly  forwards  from  the  pterion,  while  the  short 
anterior  horizontal  limb  is  indicated  by  a  line  \  an  inch 
long  drawn  forwards  from  the  same  point.  Between 
the  ascending  and  anterior  limbs  is  situated  the  pars 
triangularis  of  the  inferior  frontal  convolution  in  which 
the  centre  for  "  motor  speech "  is  placed.  The  stem 
of  the  Sylvian  fissure  is  |  an  inch  long  and  runs  down 
wards  and  forwards  under  the  great  wing  of  the  sphenoid 
(Fig.  8).     The  temporal  pole  lies  below  it. 

The  four  angles  of  the  parietal  bone  have  important 
relationships  to  the  brain.  The  anterior  inferior  angle 
covers  the  posterior  part  of  the  inferior  frontal  con- 
volution and  the  anterior  horizontal  and  ascending 
limbs  of  the  fissure  of  Sylvius.  The  anterior  branch  of 
the  middle  meningeal  artery  ascends  beneath  it.  The 
anterior  superior  angle  at  the  bregma  covers  the  terminal 
part  of  the  superior  frontal  convolution  and  the  centre 
for  movements  of  the  hip.  The  posterior  superior 
angle  at  the  bregma  lies  over  the  upper  part  of  the 
occipital  lobe  and  \  an  inch  behind  the  parietooccipital 
fissure.  The  posterior  inferior  angle  covers  the  con- 
vexity of  the  lateral  sinus  and  marks  the  lower  limit 
of  the  cerebrum.  In  its  anterior  half  the  posterior 
limb  of  the  Sylvian  fissure  lies  beneath  the  squamosal 
suture,  but  behind  it  passes  entirely  beneath  the  parietal 
bone.  It  will  be  thus  seen  that  the  parietal  bone  covers 
the  whole  of  the  parietal  lobe,  the  posterior  parts  of 
the  frontal  and  temporo-sphenoidal  lobes,  and  the  upper 
margin  of  the  occipital. 

The    inferior  temporal  convolution    passes 


Chap,  in.]         The  Cranial   Contents.  37 

backwards  above  the  upper  border  of  the  zygoma  and 
external  auditory  meatus  and  rests  on  the  thin  roof  of 
the  tympanum.  Hence  it  is  the  most  common  site 
of  abscess  which  may  follow  middle-ear  disease.   (Fig.  8.) 

The  basal  ganglia  of  the  brain — the  corpus 
striatum  and  optic  thalamus — are  capped  on  their  outer 
aspect  by  the  Island  of  Eeil.  The  Island  lies  buried 
in  the  anterior  half  of  the  fissure  of  Sylvius,  and  hence 
the  surface  markings  for  the  fissure  may  be  also  used 
for  the  Island  and  the  basal  ganglia.  A  half-circle, 
with  a  radius  of  \  an  inch,  drawn  in  front  of  the  pterion, 
will  indicate  the  anterior  limit  of  the  basal  ganglia, 
while  behind  they  terminate  behind  the  mid  point  of 
the  posterior  limb  of  the  fissure  of  Sylvius. 

A  point  taken  \\  inches  vertically  above  the  external 
auditory  meatus  marks  the  junction  of  the  descending 
and  posterior  horns  with  the  body  of  the  lateral 
ventricle.  This  point  lies  behind  the  pulvinar  of  the 
optic  thalamus. 

The  sensori-motor  areas  of  the  brain. — A 
knowledge  of  the  position  of  these  areas  is  most  important 
in  enabling  certain  brain  lesions  to  be  localised  and  in 
guiding  the  surgeon  in  operations  upon  the  cerebral 
cortex.  The  precise  extent  of  each  area  is  not  yet 
accurately  determined,  and  to  some  extent  they  over- 
lap. The  areas  in  front  and  behind  the  upper  third 
of  the  fissure  of  Rolando  are  centres  for  movements 
of  the  lower  limb  and  trunk,  the  middle  third  for  the 
upper  limb,  and  the  lower  third  for  the  face,  mouth, 
tongue,  larynx,  and  pharynx  (Fig.  8). 

The  areas  for  the  lower  limb  are  confined  to  the 
posterior  part  of  the  superior  frontal  convolution,  the 
anterior  part  of  the  superior  parietal  lobule,  and  to  the 
upper  parts  of  the  ascending  frontal  and  parietal  con- 
volutions lying  between  (Fig.  8).  Areas  for  the  lower 
limb  are  also  found  in  the  paracentral  lobule  on  the 
mesial  surface  of  the  brain.  The  hip,  knee,  ankle,  and 
the  toe  areas  are  represented  from  before  backwards.  The 
shoulder,  elbow,  wrist,  thumb  and  finger  areas  follow 
each  other  from  above  downwards  in  the  middle  third 


38  Surgical  Applied  Anatomy.     [Chap.  hi. 

of  the  ascending  frontal  and  parietal  convolutions. 
The  posterior  parts  of  the  middle  and  inferior  frontal 
convolutions,  just  anterior  to  the  ascending  frontal 
fissure,  give  rise  to  combined  movements  of  the  head 
and  eyes  when  stimulated.  The  centres  of  movement 
for  the  face,  mouth,  and. muscles  of  mastication  are 
situated  in  the  lower  third  of  the  two  ascending  con- 
volutions. The  areas  for  the  larynx  and  pharynx  lie 
in  the  pars  basilaris  of  the  third  frontal  convolution, 
while  the  motor  centre  for  speech  lies  in  the  pars 
triangularis  of  the  same  convolution.  The  "  word- 
hearing  "  centre  is  situated  in  the  superior  temporal 
convolution,  while  the  "  word-seeing  "  centre  is  placed 
in  the  angular  gyrus  (Fig.  8). 

Of  the  brain  generally  little  has  to  be  said.  In 
a  surgical  sense,  it  presents  itself  simply  as  a  large 
mass  of  soft  tissue  that  may  be  damaged  by  shaking 
as  gelatine  may  be  shaken  in  a  case.  As  it  is  of  very 
yielding  structure,  and  does  not  entirely  fill  the  cranial 
cavity,  it  may,  as  it  were,  be  thrown  about  with  the 
skull,  and  be  damaged  by  collision  with  its  walls.  Of 
the  exact  mechanism  of  concussion  or  shaking  of  the 
brain  little  is  known,  and  it  cannot  be  said  that  experi- 
ments, such  as  those  of  M.  Gama,  with  a  bulb  of  isinglass 
within  a  glass  matrass,  tend  to  throw  much  light  upon 
the  subject.  In  contusion  or  bruising  of  the  brain 
it  is  noticed  that  the  lesion  is  very  much  more  frequently 
situate  on  the  under  surface,  both  as  regards  the  cere- 
bruin  and  cerebellum,  than  any  other  part  (Prescott 
Hewett).  To  this  statement,  however,  there  is  the 
striking  exception  that  those  parts  of  the  base  of  the 
cerebrum  that  rest  upon  the  large  basal  collection  of 
the  cerebro-spinal  fluid  are  the  least  often  contused. 
These  parts  include  the  medulla,  the  pons,  and  the 
interpeduncular  space. 

The  brain  is  very  lavishly  supplied  with  blood-vessels. 
The  main  arterial  trunks  (vertebral  and  internal  carotid) 
are  both  rendered  tortuous  before  entering  the  skull, 
with  the  object  probably  of  diminishing  the  effects 
of  the  heart's  systole  upon  the   brain.       On  entering 


Chap,  in.]         The  Cranial   Contents.  39 

they  are  almost  immediately  blended  into  an  anastomos- 
ing circle  (circle  of  Willis),  which  has  the  effect  of 
equalising  the  cerebral  circulation.  Embolism  of  the 
middle  cerebral  artery  leads  to  a  wide-spread  disturb- 
ance of  the  cerebral  cortex.  It  supplies  the  third 
frontal,  the  upper  and  middle  temporal,  the  angular 
supramarginal,  and  lower  two  thirds  of  the  ascending 
frontal  and  parietal  gyri.  The  only  parts  of  the  sensori- 
motor areas  which  escape  destruction  in  such  a  case 
are  those  for  the  lower  limbs  and  trunk.  The  anterior 
cerebral  artery  supplies  these  centres,  the  mesial  surface 
of  the  frontal  and  parietal  lobes,  and  the  adjacent  part 
of  the  cortex  on  the  outer  aspect.  The  occipital  lobe 
and  temporo-sphenoidal  convolutions  are  supplied  by 
the  posterior  cerebral  artery.  Ligature  of  one  common 
carotid  may  produce  no  effect  upon  the  brain,  although 
the  mortality  after  this  operation  is  mainly  due  to 
cerebral  complications.  One  carotid  and  the  two 
vertebrals  would  appear  to  be  able  to  bring  enough 
blood  to  the  brain,  which  blood  will  be  as  evenly  dis- 
tributed as  hitherto  by  the  circle  of  Willis.  Both 
common  carotids  have  been  ligatured,  or  one  carotid 
has  been  secured,  when  its  fellow  of  the  opposite  side 
has  been  occluded  by  disease,  and  no  marked  cerebral 
disturbances  have  followed.  In  no  case,  however,  has 
the  patient  recovered  when  the  interval  between  the 
closing  of  the  two  vessels  was  less  than  a  few  weeks. 
The  vertebral  arteries  can  carry  a  sufficient  amount 
of  blood  to  the  brain  if  only  the  strain  be  thrown  upon 
them  gradually,  and  the  brain  be  allowed  to  accommodate 
itself  slowly  to  the  change.  After  ligaturing  all  four 
arteries  in  the  dog,  the  anastomosis  between  the  spinal 
and  cerebral  arteries  within  the  foramen  magnum  was 
sufficient  to  maintain  life  (Hill).  Plugging  of  any  of 
the  smaller  cerebral  arteries  by  emboli,  as  a  rule,  leads 
at  once  to  a  marked  disastrous  result.  Such  embolism 
is  met  with  in  surgery  in  connection  with  aneurism 
of  the  common  carotid.  In  simply  examining  such 
aneurisms,  a  little  piece  of  the  clot  contained  in  the 
sac  has  been  detached,  has  been  carried  up  into  the 


40  Surgical  Applied  Anatomy.     [Chap.  m. 

brain,  and  has  produced  a  plugging  of  one  of  the  cerebral 
vessels.  Thus,  hemiplegia  has  followed  upon  the  mere 
examination  of  a  carotid  aneurism,  as  in  a  case  recorded 
by  Mr.  Teale,  of  Leeds.  Fergusson's  treatment  of 
aneurism  at  the  root  of  the  neck,  by  displacing  the 
clots  by  manipulation,  has  been  abandoned  on  this 
same  score.  In  the  second  case  treated  by  manipulation 
by  this  surgeon,  a  case  of  subclavian  aneurism,  paralysis 
of  the  left  side  of  the  body  followed  at  once  upon  the 
first  handling  of  the  tumour. 

The  pulsations  of  the  brain  may  be  communicated 
to  any  tumours  or  collections  of  fluid  that  reach  the 
surface  of  the  brain  through  an  aperture  in  the  skull. 
Such  pulsations  are  synchronous  with  the  arterial 
pulse,  but  the  sphygmographic  tracings  of  the  cerebral 
pulsation  exhibit  also  the  "  respiratory  curve,"  conveyed 
directly  from  the  thorax  by  the  blood  within  the  veins. 
The  valve  at  the  lower  end  of  the  jugular  vein  prevents 
direct  regurgitation  of  blood  from  the  heart  to  the 
brain,  but  it  'does  not  prevent  the  transmission  of 
pressure. 

Although  wounds  of  the  brain  bleed  freely,  the 
bleeding  is  checked  without  difficulty,  the  vessels  being- 
capable  of  ready  contraction.  Large  tumours  have 
been  excised  from  the  cortex  of  the  brain,  without 
undue  trouble  from  haemorrhage.  The  terminal  branches 
of  the  cerebral  arteries  anastomose  freely  in  the  pia 
mater,  but  the  minute  arteries  which  perforate  and 
supply  the  cortex  are  terminal.  Hence  any  pressure 
applied  to  the  surface  of  the  brain  will  lead  to  anaemia 
of  that  piece  of  cortex,  and,  if  the  pressure  is  continued, 
to  its  destruction. 


41 


CHAPTER  IV. 

THE    ORBIT    AND    EYE. 

The  orbit. — The  antero-posterior  diameter  of  the 
orbit  is  about  If  inches,  its  vertical  diameter  at  the 
base  a  little  over  1|-  inches,  and  its  horizontal  dia- 
meter at  the  base  about  l|  inches.  The  diameters  of 
the  globe  are  as  follow  :  transverse,  24  mm.  ;  antero- 
posterior, 24'5  mm.  ;  vertical,  23  mm.  (Brailey).  The 
eye-ball  is  therefore  nearer  to  the  upper  and  lower 
margins  of  the  orbit  than  it  is  to  the  sides,  and  the 
greatest  interval  between  the  globe  and  the  orbital 
wall  is  on  the  outer  side.  The  interior  of  the  orbit  is 
most  conveniently  reached  by  incisions  made  to  the 
outer  side  of  the  globe,  and,  in  excision  of  the  eye-ball, 
the  scissors  are  usually  introduced  on  that  side  when 
the  optic  nerve  has  to  be  divided.  In  excising  the  left 
eye,  however,  it  may  be  more  convenient  to  divide  the 
optic  nerve  from  the  inner  side.  The  bones  forming 
the  floor,  the  roof,  and  the  inner  wall  of  the  orbital 
cavity  are  very  thin,  especially  in  the  last-named  situa- 
tion. Thus,  foreign  bodies  thrust  into  the  orbit  have 
readily  penetrated  into  the  cranial  cavity,  into  the  nose 
and  ethmoidal  cells,  and,  when  directed  from  above, 
into  the  antrum.  In  several  instances,  a  sharp-pointed 
substance,  such  as  the  end  of  a  stick  or  foil,  has  been 
thrust  into  the  brain  through  the  orbit,  and  has  left 
but  little  external  evidence  of  this  serious  lesion.  Nelaton 
mentions  a  case  in  which  the  internal  carotid  artery 
was  wounded  through  the  orbit.  Certain  cases  of 
pulsating  orbital  tumour  which  depend  upon  a  com- 
munication between  the  carotid  artery  and  the  cavernous 
sinus  have  a  traumatic  origin. 

A  reference  to  the  relations  of  the  orbital  walls  will 
show  that  a  tumour  may  readily  invade  the  orbit  by 
spreading  (1)  from  the  base  of  the  skull,  (2)  from  the 
nasal  fossae,  (3)  from  the  antrum,  and  (4)  from  the 
temporal  or  zygomatic  fossa1.     In  any  of  these  instances 


42  Surgical  Applied  Anatomy.      [Chap.  iv. 

the  growth  may  enter  the  orbit  by  destroying  the  inter- 
vening thin  layers  of  bone,  and  in  tumours  of  the  antrum 
this  is  the  usual  mode  of  entry.  It  may,  however, 
extend  more  readily  from  the  cranial  cavity  through 
the  optic  foramen  or  sphenoidal  fissure,  from  the  nose 
through  the  nasal  duct,  and  from  the  two  fossse  named, 
through  the  sphe no-maxillary  fissure.  After  violent 
blows  upon  the  temple  blood  has  found  its  way  into 
the  orbit  through  the  spheno-maxillary  fissure,  and 
has  led  to  subconjunctival  ecchymosis.  Distension  of 
the  frontal  sinus  by  retained  mucus  or  pus  may  lead 
to  a  prominent  tumour  at  the  upper  and  inner  margin 
of  the  orbit,  above  the  level  of  the  tendo  oculi,  which 
may  cause  displacement  of  the  globe  downwards,  out- 
wards, and  forwards.  The  bones  of  the  orbit  are 
peculiarly  apt  to  be  the  seat  of  ivory  exostoses,  which 
may  in  time  entirely  occupy  the  orbital  cavity.  At  the 
upper  and  outer  angle  of  the  orbit  a  congenital  sebaceous 
cyst  is  sometimes  met  with.  It  lies  beneath  the  orbi- 
cularis muscle,  and  is  often  connected  at  some  depth 
with  the  orbital  periosteum. 

The  capsule  of  Tenon.— The  best  description 
of  this  capsule  has  been  given  by  Mr.  Lockwood ;  of 
his  researches  Prof.  Cunningham  provides  the  following 
resume  : — 

The  capsule  is  a  firm  loose  membrane  spread  over 
the  posterior  |ths  of  the  globe,  the  cornea  alone  being 
free  from  it.  In  front  it  lies  under  the  ocular  con- 
junctiva, with  which  it  is  intimately  connected,  and  it 
ends  by  blending  with  that  membrane  close  to  the 
margin  of  the  cornea.  Behind  it  fuses  with  the  sheath 
of  the  optic  nerve,  where  the  latter  pierces  the  sclerotic. 
The  surface  of  the  membrane  towards  the  globe  is 
smooth,  and  is  connected  to  the  eye-ball  by  some  soft 
yielding  areolar  tissue.  It  thus  forms  a  kind  of  dome 
for  the  globe,  a  species  of  socket  or  bursa  in  which  it 
moves.  The  posterior  surface  of  the  capsule  is  in  con- 
tact with  the  orbital  fat.  The  tendons  of  the  ocular 
muscles  pierce  the  capsule  opposite  the  equator  of  the 
globe.     The  lips  of  the  openings  through  which  the  four 


Chap,  iv.]  The  Orbit  and  Eye.  43 

recti  pass  are  prolonged  backwards  upon  the  muscles, 
in  the  form  of  sheaths,  very  much  as  the  inf  undibuliform 
fascia  is  prolonged  upon  the  cord  from  the  internal 
abdominal  ring.  Mr.  Lockwood  points  out  that  each 
of  these  four  apertures  is  strengthened  by  a  slip 
of  fibrous  tissue,  the  intracapsular  ligament.  As 
the  capsule  is  fixed  at  various  points  to  the  wall  of  the 
orbit,  these  ligaments  act  as  pulleys,  and  protect  the 
globe  from  pressure  during  contraction  of  the  muscles. 
When  the  insertions  of  the  recti  muscles  are  divided 
in  cases  of  strabismus,  the  capsule  is  distinctly  seen 
after  the  conjunctiva  has  been  cut  through,  and  requires 
also  to  be  divided  before  the  section  of  the  muscle  can 
be  properly  made.  The  capsule  is  of  some  importance 
in  this  procedure.  After  its  division  the  muscle  does 
not  entirely  retract  and  lie  shrunken  within  the  orbit. 
Its  connections  with  the  capsule  still  give  it  some  hold 
upon  the  globe,  and  still  enable  it  to  act  upon  that  struc- 
ture. Moreover,  the  attachments  of  the  capsule  to  the 
margins  of  the  orbit  prevent  the  muscles  from  entirely 
retracting,  and  even  when  the  globe  has  been  removed, 
they  give  them  some  basis  to  act  upon,  and  thus  tend 
to  preserve  some  little  mobility  in  the  stump. 

Of  these  orbital  attachments  the  suspensory  liga- 
ment of  Lockwood  is  the  most  important.  It  stretches 
across  the  fore  part  of  the  orbit  after  the  fashion  of  a 
hammock,  and  supports  the  eye-ball.  Its  two  extremi- 
ties are  attached  respectively  to  the  malar  and  lachrymal 
bones.  Below  the  eye-ball  it  widens  out,  and  blends 
with  the  capsule  of  Tenon.  Strong  bands,  known  as 
the  check  ligaments,  pass  from  the  sheaths  of  the  external 
and  internal  recti  muscles  to  the  malar  and  lachrymal 
bones  respectively.  They  limit  excessive  rotation  of 
the  globe  in  an  outward  or  inward  direction.  The 
action  of  the  superior  rectus  is  checked  by  its  connec- 
tion with  the  levator  palpebral,  and  that  of  the  inferior 
rectus  by  the  connection  of  its  tendon  with  the  suspensory 
ligament. 

Mr.  Lockwood  points  out  that  in  removing  the 
upper  jaw  the  surgeon  should   take   car.:-   to   preserve 


44  Surgical  Applied  Anatomy.      [Chap.  iv. 

the  attachments  of  the  suspensory  ligaments.  If  these 
be  destroyed  the  eye-ball  sinks  downwards. 

The  orbit  behind  Tenon's  fascia  is  occupied  by  a 
large  quantity  of  loose  fat,  in  addition  to  the  ocular 
muscles,  the  vessels,  and  nerves.  It  is  by  the  absorp- 
tion of  this  fat  that  the  sunken  eye  is  produced  in  cases 
of  emaciation  and  prolonged  illness.  This  tissue  affords 
a  ready  means  for  the  spread  of  orbital  abscess. 
Such  an  abscess  may  follow  injuries,  certain  ocular 
inflammations,  periostitis,  etc.,  or  may  spread  from 
adjacent  parts.  The  pus  may  occupy  the  entire  cavity, 
displacing  the  eye-ball  forwards,  limiting  its  movements, 
and  causing,  by  interference  with  the  circulation,  great 
redness  of  the  conjunctiva  and  swelling  of  the  lids. 

Foreign  bodies,  some  of  them  of  remarkable  size 
and  shape,  have  lodged  for  long  periods  of  time  in  the 
orbital  fat  without  causing  much  trouble.  Thus  Lawson 
reports  a  ease  where  a  piece  of  an  iron  hat-peg,  three 
inches  long,  was  embedded  in  the  orbit  for  several  days 
without  the  patient  being  aware  of  it.  A  stranger  case, 
in  some  ways,  is  that  reported  by  Furneaux  Jordan  : 
"  A  man,  who  was  employed  in  threshing,  became  the 
subject  of  severe  ophthalmia.  At  the  expiration  of 
several  weeks,  the  patient,  whilst  pressing  his  finger  on 
the  lower  eyelid,  suddenly  ejected  from  a  comfortable 
bed  of  warm  pus  a  grain  of  wheat,  which  had  shot  forth 
a  vigorous  green  sprout."  The  orbital  fat  affords  also 
ail  excellent  nidus  for  growing  tumours.  Fractures  of 
the  inner  wall  of  the  orbit  involving  the  nasal  fossae  or 
sinuses,  may  lead  to  extensive  emphysema  of  the  orbital 
cellular  tissue.  The  air  so  introduced  may  cause  the 
globe  to  protrude,  may  limit  its  movements,  may  spread 
to  the  lids,  and  will,  in  any  case,  be  increased  in  amount 
by  blowing  the  nose,  etc. 

The  orbital  muscles.— The  four  recti  muscles 
end  in  thin,  flat  membranous  tendons.  The  tendon 
of  the  external  or  internal  rectus  muscle  is  frequently 
divided  for  strabismus.  The  width  of  the  tendons 
varies  from  7  mm.  to  9  mm.  They  are  inserted  into 
the  sclerotic  near  the  cornea.     The  internal  rectus  is 


chap,  iv.]  The  Orbit  and  Eye.  45 

inserted  6'o  mm.  from  the  corneal  margin,  the  external 
6*8  mm.,  the  inferior  7'2  mm.,  and  the  superior  8  mm. 
(Merkel). 

The  external  and  inferior  recti  arc  the  longest,  the 
internal  rectus  is  the  broadest,  and  the  superior  is  the 
narrowest  and  slightest. 

The  orbital  arteries  are  small,  and  seldom  give 
rise  to  trouble  when  divided  in  excising  the  globe,  since 
they  can  be  readily  compressed  against  the  bony  walls 
of  the  cavity.  Pulsating  tumours  of  this  part  may  be 
due  to  traumatic  aneurisms  of  one  of  the  orbital  arteries, 
or  may  depend  upon  an  arterio-venous  aneurism  formed 
between  the  internal  carotid  artery  and  the  cavernous 
sinus.  Pressure  also  upon  the  ophthalmic  vein  (as  it 
enters  the  sinus),  by  an  aneurism  of  the  internal  carotid 
vessel,  may  produce  all  the  symptoms  associated  with 
pulsating  orbital  tumours. 

The  orbital  nerves  may  be  damaged  in  wounds 
of  the  orbit,  or  in  fractures  of  the  orbit  and  of  the  base 
of  the  skull.  They  may  be  pressed  upon  by  tumours 
from  various  parts,  by  aneurisms,  hemorrhagic  and 
inflammatory  effusions.  Thus  Lawson  records  a  case 
in  which  the  optic  nerve  was  divided  by  a  stab  through 
the  upper  eyelid,  without  the  globe  being  injured,  and 
without  any  bone  being  fractured.  The  same  nerve 
has  also  been  completely  torn  across  in  fractures  of  the 
orbit,  and  has  been  pressed  upon  in  fractures  involving 
the  lesser  wing  of  the  sphenoid.  The  third,  fourth,  and 
sixth  nerves,  and  the  first  division  of  the  fifth,  may  be 
affected  in  cases  of  aneurism  involving  the  internal 
carotid  artery,  where  they  lie  in  relation  with  the  cavern- 
ous sinus.  They  may  readily  be  pressed  upon,  also, 
by  any  growth  involving  the  sphenoidal  fissure,  such  as 
a  periosteal  node  springing  from  the  margin  of  the 
fissure,  while  the  sixth  nerve,  from  its  more  intimate 
connection  with  the  base  of  the  skull,  has  been  directly 
torn  across  in  a  fracture  involving  that  part  (Prescott 
Hewett). 

In  paralysis  of  the  third  nerve  there  is 
drooping  of  the  upper  lid  (ptosis) ;    the  eye  is  almost 


46  Surgical  Applied  Anatomy.      [Chap.  iv. 

motionless,  presents  a  divergent  squint  from  unop- 
posed action  of  the  external  rectus  muscle,  and  cannot 
be  moved  either  inwards,  upwards,  or  directly  down- 
wards. Rotation,  in  a  direction  downwards  and  out- 
wards, can  still  be  effected  by  the  superior  oblique  and 
outer  rectus  muscles.  The  pupil  is  dilated  and  fixed  ; 
the  power  of  accommodation  is  much  impaired,  there 
is  diplopia,  and  sometimes  a  little  protrusion  of  the 
globe  from  relaxation  of.  tho,  recti  muscles.  These 
symptoms  refer  to  complete  paralysis  of  the  nerve.  In 
cases  of  partial  paralysis,  only  one  or  two  of  the  above 
symptoms  may  be  present. 

In  paralysis  of  the  fourth  nerve  there  is 
often  but  little  change  to  be  seen,  since  the  function  of 
the  superior  oblique  muscle,  supplied  by  this  nerve,  may, 
in  part,  be  performed  vicariously.  "  There  is  usually 
only  very  slight  defect  in  the  mobility  of  the  eye  ;  what 
there  is  occurs  chiefly  in  the  inner  and  lower  angle 
of  the  field  of  vision  ;  there  is  deviation  of  the  eye  inwards 
and  upwards  on  lowering  the  object,  and  simply  upwards 
when  it  is  turned  far  towards  the  healthy  side  "  (Erb). 
In  any  case  there  will  be  diplopia,  especially  in  certain 
positions  of  the  globe. 

In  paralysis  of  the  sixth  nerve  there  is  con- 
vergent strabismus,  with  consequent  diplopia,  and  an 
inability  to  rotate  the  eye  directly  outwards.  Paralysis 
of  the  sixth  nerve  may  be  accompanied  by  paralysis 
of  the  nerve  to  the  internal  rectus  of  the  opposite  side, 
giving  rise  to  conjugate  deviation  of  the  eyes.  Such 
a  condition  indicates  a  lesion  in  the  nucleus  of  the  sixth 
nerve,  for  although  the  fibres  for  the  internal  rectus 
pass  out  with  the  third  nerve  they  take  their  origin 
with  the  sixth. 

Sometimes  all  the  oculo-motor  nerves  of  the  eye 
are  paralysed,  and  in  such  cases  the  lesion  is  probably 
situated  either  at  their  nuclei  or  origin  or  at  the 
cavernous  sinus,  in  the  wall  of  which  the^nerves  lie 
close  together. 

In  paralysis  of  the  first  division  of  the  fifth 
there  is  a  loss  of  sensation  in  all  the  conjunctiva,  except 


chap,  iv.]  The  Orbit  and  Eve.  47 

such  as  covers  the  lower  lid  (supplied  by  the  palpebral 
branch  of  the  infraorbital  nerve),  loss  of  sensation  in 
the  globe,  and  in  skin  supplied  by  the  supratrochlear 
and  supraorbital  nerves,  and  in  the  mucous  and  cuta- 
neous surfaces  supplied  by  the  nasal  nerve.  The  area 
of  anaesthesia  is  much  less  than  the  anatomical  dis- 
tribution of  the  nerve,  owing  to  the  extent  to  which 
cutaneous  nerves  overlap.  No  reflex  movements 
(winking)  follow  upon  irritation  of  the  conjunctiva, 
although  the  patient  can  be  made  to  wink  on  exposing 
the  eye  to  a  strong  light,  the  optic  nerve  in  this  case 
transmitting  the  impression  to  the  facial  nerve. 
Sneezing  also  cannot  be  excited  by  irritating  the  mucous 
membrane  in  the  anterior  part  of  the  nose.  Destructive 
ulceration  of  the  cornea  may  follow  this  paralysis,  due 
partly  to  damage  to  the  trophic  branches  contained 
in  the  paralysed  nerve,  partly  to  the  anaesthesia  which 
renders  the  part  readily  injured,  and  partly  to  the  loss 
of  the  reflex  effect  of  the  sensory  nerves  upon  the  calibre 
of  the  blood-vessels,  whereby  the  inflammation  is 
permitted  to  go  uncontrolled  (Nettleship). 

In  paralysis  of  the  cervical  sympathetic 
there  is  narrowing  of  the  palpebral  fissure  from  some 
drooping  of  the  upper  lid,  apparent  recession  of  the 
globe  within  the  orbit,  and  some  narrowing  of  the 
pupil  from  paralysis  of  the  dilator  muscle  of  the  iris, 
which  muscle  is  supplied  by  the  sympathetic.  The 
drooping  of  the  upper  lid  may  be  explained  by  the  fact 
that  each  eyelid  contains  a  layer  of  unstriated  muscle 
fibre.  That  in  the  upper  lid  arises  from  the  under 
surface  of  the  levator  palpebral,  and  is  attached  to  the 
tarsal  cartilage  near  its  upper  margin  (Fig.  12).  This 
layer  of  muscle,  which,  when  in  action,  would  keep 
up  the  lid,  is  under  the  influence  of  the  cervical 
sympathetic.  The  recession  of  the  globe  is  supposed 
by  some  to  be  due  to  paralysis  of  the  orbitalis  muscle 
of  H.  Miiller.  This  muscle  bridges  over  the  spheno- 
maxillary fissure,  is  composed  of  unstriated  fibres,  and 
is  innervated  by  the  sympathetic.  Contraction  of  the 
muscle    (as    produced    by    irritation    of    the    cervical 


48 


Surgical  Applied  Anatomy.      [Chap.  I  v. 


sympathetic  in  animals)  causes  protrusion  of  the  globe, 
while  section  of  the  sympathetic  in  the  neck  produces 
retraction  of  the  eye-ball  (CI.  Bernard).  No  changes 
are  observed  in  the  calibre  of  the  blood-vessels  of  the 
globe. 

The  globe  ;  the  cornea.— The  thickness  of  the 
cornea  varies  from  '9  mm.  in  the  central  parts  to  l'l  mm. 
at  the  periphery.  One  is  apt  to  be  a  little  deceived  as 
to  its  thickness,  and  on  introducing  a  knife  into  the 
cornea,  the  instrument,  if  not  entered  at  the  proper 
angle,  may  be  thrust  for  some  little  distance  among 
the  laminse  of  the  part.  In  front  the  cornea  is  covered 
by  stratified  epithelium.  When  this  layer  has  been 
removed  by  abrasion,  a  white  deposit  of  lead  salts  may 
take  place  in  the  exposed  corneal  tissue  in  cases  where 
lead  lotions  are  used.  The  bulk  of  the  cornea  is  made 
up  of  a  great  number  of  fibrous  lamelhe,  between  which 
are  anastomosing  cell  spaces  containing  the  corneal 
corpuscles.     If  the  nozzle  of  a  fine  syringe  he  thrust 


Fig.  10.-A  Horizontal  Section  of  the  Globe  through  the  middle. 


a-  Cornea  ;  b,  sclerotic  ;  c,  choroid  ;  d.  retina  ;  e,  lens  ;  /,  iris ;  g,  ciliary  process 
7;,  canal  of  Sculemm. 


Chap,  iv.i  The  Orbit  axd  Eye.  49 

into  the  corneal  tissue,  the  network  of  cell  spaces  can 
be  filled  with  injection  (Recklinghausen's  canals).  When 
suppuration  takes  place  within  the  proper  corneal 
tissue,  it  is  probably  along  these  canals,  modified  by 
inflammation,  that  the  pus  spreads,  thus  producing 
onyx.  The  cornea  contains  no  trace  of  blood-vessels, 
except  at  its  extreme  periphery,  where  the  capillaries 
of  the  sclerotic  and  conjunctiva  end  in  loops.  This 
lack  of  a  direct  blood  supply  renders  the  cornea  prone  to 
inflame  spontaneously  in  the  cachectic  and  ill-nourished. 
When  inflamed,  the  tissue  always  becomes  opaque. 
In  the  affection  known  as  interstitial  keratitis,  blood- 
vessels from  the  arteries  at  the  margin  of  the  cornea 
penetrate  into  the  substance  of  the  cornea  for  some 
distance.  As  these  vessels  will  be  some  little  way  below 
the  surface,  and  will  be  covered  by  the  hazy  corneal 
tissue  that  is  the  result  of  the  disease,  their  scarlet 
colour  is  much  toned  down,  and  a  strand  of  such  vessels 
is  called  a  "  salmon  patch."  In  the  condition  known 
as  pannus,  the  cornea  appears  to  be  vascularised  ;  but 
here,  owing  to  continued  irritation,  vessels,  derived 
from  the  neighbouring  conjunctival  arteries,  pass  over 
the  cornea  just  beneath  its  epithelial  covering,  leaving" 
the  cornea  proper  as  bloodless  as  ever.  The  term  arcus 
senilis  is  applied  to  two  narrow  white  crescents  that 
appear  at  the  periphery  of  the  cornea,  just  within  its 
margin,  in  the  aged,  and  in  certain  morbid  conditions. 
The  crescents  are  placed  at  the  upper  and  lower  margins, 
and  their  points  meet  midway  on  either  side  of  the 
cornea.  They  are  due  to  fatty  degeneration  of  the 
corneal  tissue,  and  the  change  is  most  marked  in  the 
layers  of  the  cornea  just  beneath  the  anterior  elastic 
lamina,  i.e.  in  the  part  most  influenced  by  the  marginal 
blood-vessels.  In  spite  of  its  lack  of  a  direct  blood  supply, 
wounds  of  the  cornea  heal  kindly.  The  cornea  is  very 
lavishly  supplied  with  nerves,  estimated  to  be  from 
forty  to  forty-five  in  number.  They  are  derived  from 
the  ciliary  nerves,  enter  the  cornea  through  the  fore 
part  of  the  sclerotic,  and  are  distributed  to  every  part 
of   the    tunic.      In    glaucoma,  a    disease   of   which  the 


50  Surgical  Applied  Anatomy.      [Chap. IV, 

phenomena  depend  upon  greatly  increased  intraocular 
pressure,  the  cornea  becomes  anaesthetic.  This  depends 
upon  the  pressure  to  which  the  ciliary  nerves  are  exposed 
before  their  branches  reach  the  cornea.  (See  also  Nerve 
supply  of  the  eye-ball,  page  54.) 

The  sclerotic,  choroid,  and  iris,— The  sclerotic 
is  thickest  behind,  and  thinnest  about  \  of  an  inch 
from  the  cornea.  When  the  globe  is  ruptured  by 
violence  it  is  the  sclerotic  that  most  commonly  yields, 
the  rent  being  most  usually  a  little  way  from  the  cornea, 
i.e.  in  or  about  the  thinnest  part  of  the  tunic.  A  rupture 
of  the  cornea  alone  from  violence  is  not  common.  The 
sclerotic  may  be  ruptured  while  the  lax  conjunctiva 
over  it  remains  untorn.  In  such  a  case  the  lens  may 
escape  through  the  rent  in  the  sclerotic,  and  be  found 
under  the  conjunctiva.  At  the  point  of  penetration 
of  the  optic  nerve  the  sclerotic  is  thin,  and  pierced  by 
numerous  holes  for  the  passage  of  nerve  bundles.  This 
weakened  part,  the  lamina  cribrosa,  plays  an  important 
part  in  glaucoma  (page  62).  It  gives  the  stippled 
appearance  to  the  optic  papilla.  Brailey  states  that 
the  lateral  parts  of  the  sclerotic  are  thinner  than  the 
upper  and  lower  segments,  the  inferior  part  being  the 
thickest  and  the  external  wall  the  thinnest.  It  happens, 
therefore,  that  under  the  influence  of  intraocular 
pressure  the  eye  expands  more  laterally  than  in  the 
vertical  direction.  It  is  mainly  to  the  denseness  and 
unyielding  character  of  the  sclerotic  that  must  be 
ascribed  the  severe  pain  (due  to  pressure  on  nerves) 
experienced  in  those  eye  affections  associated  with 
increased  intraocular  tension  (glaucoma,  etc). 

The  choroid  is  the  vascular  tunic  of  the  globe,  and 
carries  its  main  blood-vessels.  Between  the  choroid  and 
sclerotic  are  two  thin  membranes,  the  lamina  supra- 
choroidea  and  lamina  fusca,  which  are  separated 
from  one  another  by  a  lymph  space.  In  injuries  to  the 
globe,  therefore,  extensive  bleeding  may  take  place 
between  these  two  coats,  and  indeed  a  like  haemorrhage 
may  be  the  result  simply  of  a  sudden  diminution  in 
the  ocular  tension  produced  by  such  an  operation  as 


chap,  rv.j  The  Orbit  and  Eye.  51 

iridectomy  or  cataract  extraction.  The  choroid  alone 
has  been  ruptured  (usually  at  its  posterior  part)  as  the 
result  of  a  blow  upon  the  front  of  the  eye.  The  choroid 
is  one  of  the  few  parts  of  the  body  that  may  be  the  seat 
of  melanotic  growths.  These  growths  are  sarcomatous 
tumours  containing  a  large  amount  of  pigment, 
and  occur  only  where  pigment  cells  are  found.  In 
the  choroid  coat  pigment  cells  are  very  abundant. 

The  itis  is,  from  its  great  vascularity,  very  easily  in- 
flamed. From  its  relations  to  the  cornea  and  sclerotic 
it  happens  that  inflammation  in  those  tunics  can  spread 
without  difficulty  to  the  iris.  On  the  other  hand,  the 
vessels  of  the  iris  and  choroid  are  so  intimately  related 
that  inflammations  set  up  in  the  iris  itself  have  every 
inducement  to  spread  to  the  choroidal  tunic.  When 
the  iris  is  inflamed  its  colour  becomes  altered,  owing 
to  the  congestion  of  the  part  and  to  the  effusion  of 
lymph  and  serum  that  takes  place  in  its  substance. 
The  swelling  to  which  it  becomes  subject,  together 
with  the  effusion,  produce  a  blurring  of  its  delicate, 
reticulated  structure,  as  seen  through  the  cornea. 
Owing  also  to  the  swollen  condition  of  the  little  mem- 
brane, the  pupil  becomes  encroached  on,  and  appears 
to  be  contracted,  while  the  movements  of  the  mem- 
brane are  necessarily  rendered  very  sluggish.  If  it  be 
remembered  that  the  greater  part  of  the  posterior 
surface  of  the  iris  is  in  actual  contact  with  the  lens 
capsule,  it  will  be  understood  that  inflammatory  ad- 
hesions may  readily  take  place  between  the  two  parts 
(Fig.  11).  After  iritis,  therefore,  it  is  common  to  find 
the  posterior  surface  of  the  iris  (most  often  its 
pupillary  margin)  adherent  to  the  lens  capsule  by 
bands  of  lymph,  either  entirely  or  in  one  or  more 
different  points.  Such  adhesions  constitute  posterior 
synechias,  the  term  anterior  synechia  being  applied  to 
adhesions  between  the  iris  and  the  cornea.  In  iritis 
also  the  lens  may  become  involved,  and  the  condition 
of  secondary  or  inflammatory  cataract  be  produced. 
The  iris  is  not  very  closely  attached  at  its  insertion. 
Thus,  in  case  of  injury  to  the  eye,  it  may  be  torn  more 


52  Surgical  Applied  Anatomy,      [cbap. iv. 

or  less  from  its  attachments  without  any  damage  being 
done  to  the  other  tunics.  The  iris  has  been  completely 
torn  away  in  a  few  instances,  and  has  escaped  through 
a  wound  of  the  globe.  The  ciliary  processes  have  been 
thus  exposed.  Congenital  absence  of  the  iris  has  been 
recorded.  In  cases  of  penetrating  wounds  of  the  cornea 
the  iris  is  easily  prolapsed.  It  is  so  delicate  and  yielding 
a  membrane  that  in  performing  iridectomy  the  necessary 
piece  of  the  iris  can  be  seized  and  pulled  out  through 
the  corneal  incision  without  offering  sensible  resistance. 
The  membrane  also  derives  much  support  from  its 
contact  with  the  lens,  for  in  cases  where  the  lens  has 
been  displaced  into  the  vitreous,  or  has  been  removed 
by  operation,  the  iris  is  observed  to  be  tremulous  when 
the  globe  is  moved.  Although  very  vascular,  the  iris 
seldom  bleeds  much  when  cut,  a  circumstance  that  is 
probably  due  to  the  contraction  of  the  muscular  fibres 
that  exist  so  plentifully  within  it.  Sometimes  the  iris 
presents  a  congenital  gap  in  its  substance  that  runs 
from  the  pupil  downwards  and  a  little  inwards.  This 
condition  is  known  as  coloboma  iridis,  and  is  due  to 
the  persistence  of  the  "  choroidal  cleft."  In  other  cases 
there  can  be  seen,  stretching  across  the  pupil,  some 
shreds  of  the  pupillary  membrane.  Normally  this 
membrane,  which  is  apparent  for  a  few  days  after  birth 
in  some  animals,  is  entirely  absorbed  before  birth. 

It  will  now  be  convenient  to  take  note  of  the  blood 
and  nerve  supply  of  the  globe. 

Blood  supply  of  the  eye-ball.— 1.  The  short 
ciliary  arteries  (from  the  ophthalmic)  pierce  the  sclerotic 
close  to  the  optic  nerve,  run  some  little  way  in  the  outer 
coat  of  the  choroid,  and  then  break  up  into  a  capillary 
plexus  that  makes  up  the  main  part  of  the  inner  choroidal 
coat.  In  front  this  plexus  gives  some  vessels  to  the 
ciliary  processes.  The  veins  from  these  vessels  are 
disposed  in  curves  as  they  converge  to  four  or  five  main 
trunks  (venae  vorticosse),  which  pierce  the  sclerotic 
midway  between  the  cornea  and  the  optic  nerve.  In 
the  choroid  they  lie  external  to  the  arteries. 

2.  The     two     long     ciliary     arteries     (from     the 


chap,  iv.]  The  Orbit  and  Eve.  53 

ophthalmic)  pierce  the  sclerotic  to  the  outer  side  of  the 
optic  nerve,  and  run  forwards,  one  on  either  side,  until 
they  reach  the  ciliary  region,  where  they  break  up 
into  branches  that,  by  anastomosing,  form  a  vascular 
circle  about  the  periphery  of  the  iris  (the  circulus 
major).  From  this  circle  some  branches  pass  to  the 
ciliary  muscle,  while  the  rest  run  in  the  iris  in  a  con- 
verging manner  towards  the  pupil,  and  at  the  margin 
of  the  pupil  form  a  second  circle  (the  circulus  minor). 

3.  The  anterior  ciliary  arteries  (from  the  muscular 
and  lachrymal  branches  of  the  ophthalmic)  pierce  the 
sclerotic  (perforating  branches)  about  a  line  behind 
the  cornea,  join  the  circulus  major,  and  give  off  branches 
to  the  ciliary  processes,  where  they  form  copious  anasto- 
mosing loops.  These  arteries  lie  in  the  subconjunctival 
tissue.  Their  episcleral  or  non-perforating  branches 
are  very  small  and  numerous,  and  are  invisible  in  the 
normal  state  of  the  eye.  In  inflammation,  however, 
of  the  iris  and  adjacent  parts,  these  vessels  appear  as  a 
narrow  pink  zone  of  fine  vessels  round  the  margin  of" 
the  cornea,  that  run  nearly  parallel  to  one  another, 
are  very  closely  set,  and  do  not  move  with  the  con- 
junctiva. This  zone  is  known  as  the  zone  of  ciliary 
congestion,  or  the  circumcorneal  zone, 

4.  The  vessels  of  the  conjunctiva  are  derived  from 
the  lachrymal  and  the  two  palpebral  arteries.  These 
vessels,  in  cases  of  inflammation,  are  readily  distinguished 
from  those  last  described.  They  are  of  comparatively 
large  size,  are  tortuous,  are  of  a  bright  brick-red  colour, 
can  be  easily  moved  with  the  conjunctiva,  and  as  easily 
emptied  of  their  blood  by  pressure.  The  differences 
presented  by  these  two  sets  of  vessels  serve  in  one  way 
to  distinguish  inflammation  of  the  conjunctiva  from  that 
involving  deeper  parts.  The  conjunctival  vessels  around 
the  margin  of  the  cornea  form  a  closer  plexus  of  anasto- 
mosing capillary  loops,  which  become  congested  in 
severe  superficial  inflammation  of  the  cornea,  and  may 
then  form  a  zone  around  the  margin  of  the  cornea,  which 
can,  however,  be  distinguished  from  the  "  ciliary  zone  " 
by    the    general    characters    just    named,     The    retina 


54  Surgical  Applied  Anatomy.      [Chap  iv. 

has  a  vascular  system  of  its  own,  supplied  through  the 
arteria  centralis  retina,  which  is  nowhere  in  direct 
communication  with  the  choroidal  vessels,  except  just 
at  the  entrance  of  the  optic  nerve.  Indeed,  the  outer 
layers  of  the  retina  which  are  in  relation  with  the  choroid 
coat  are  entirely  destitute  of  vessels.  Thus,  when  the 
central  artery  of  the  retina  becomes  plugged,  sudden 
blindness  follows,  and  as  the  meagre  collateral  circula- 
tion that  is  established  by  the  minute  anastomoses 
about  the  entrance  of  the  nerve  is  quite  insufficient, 
the  retina  soon  becomes  cedematous.  A  permanent 
plugging  of  the  central  artery  means,  therefore,  a 
practical  extinction  of  the  vascular  system  of  the 
retina.  In  some  cases  of  embolism  only  a  branch  of 
the  retinal  artery  is  plugged,  the  patient  retaining 
vision  except  in  that  part  of  the  retina  supplied  by  the 
branch.  The  fovea  centralis,  the  centre  of  acute  vision, 
receives  twigs  from  both  the  superior  and  inferior 
temporal  branches  of  the  arteria  centralis  retinae. 

In  cases  of  haemorrhage  between  the  choroid  and 
retina  the  blood  must  come  from  the  choroidal  vessels  ; 
and  in  haemorrhage  into  the  vitreous,  which  often 
follows  injury,  the  blood  may  be  derived  from  the  retinal 
vessels,  since  they  run  in  the  inner  layers  of  that  mem- 
brane, or  from  the  vessels  in  the  ciliary  region. 

Nerve  supply  of  the  eye-ball.— 1.  The  ciliary 
nerves  derived  from  the  lenticular  ganglion  and  the 
nasal  nerve  pierce  the  sclerotic  close  to  the  optic  nerve, 
and  pass  forwards  between  the  sclerotic  and  the  choroid, 
supplying  those  parts.  They  enter  the  ciliary  muscle, 
form  a  plexus  about  the  periphery  of  the  iris,  and  then 
send  fibres  into  the  iris,  which  form  a  fine  plexus  as 
far  as  the  pupil.  They  send  branches  through  the  fore 
part  of  the  sclerotic  to  the  cornea.  Thus  the  eye-ball 
obtains  through  these  nerves  its  sensory  fibres  from 
the  nasal  branch  of  the  first  division  of  the  fifth,  its  motor 
fibres  for  the  ciliary  muscle  and  sphincter  iridis  from 
the  third  nerve,  and  many  sympathetic  fibres,  among 
which  are  those  that  supply  the  dilator  muscle  of  the 
iris.     2,  The  conjunctiva  is  supplied  by  four  nerves  : 


chap,  iv.]  The   Orbit  and  Eye.  55 

above,  the  supratrochlear  ;  on  the  inner  side  by  the 
infratrochlear  ;  on  the  outer  side,  the  lachrymal  (all 
branches  of  the  first  division  of  the  fifth) ;  and  below 
by  the  palpebral  branches  of  the  second  division  of  the 
fifth.  As  the  ciliary  nerves  pass  forwards  between  the 
choroid  and  the  sclerotic,  it  will  be  seen  that  they  are 
readily  exposed  to  injurious  pressure  against  the  un- 
yielding sclerotic  in  cases  of  increased  intraocular  tension. 
The  sensation  of  the  globe  itself  is  derived  solely 
from  the  first  division  of  the  fifth.  In  inflammatory 
affections  of  the  globe,  as  in  corneitis  or  iritis,  besides 
the  pain  actually  felt  in  the  eye,  there  is  pain  referred 
along  other  branches  of  the  first  division  of  the  fifth. 
The  explanation  of  this  fact  has  to  be  sought  for  in  the 
common  origin  of  the  ophthalmic  division  from  the  upper 
sensory  nucleus  of  the  fifth  nerve  in  the  floor  of  the  fourth 
ventricle.  Not  only  are  the  nerve  cells  connected  with 
the  eye-ball  disturbed,  but  the  neighbouring  cells  are 
also  affected,  and  by  a  psychical  error  the  pain  is  re- 
flected along  the  nerves  with  which  they  are  connected. 
There  is  pain  over  the  forehead  along  the  supratrochlear, 
supraorbital,  and  lachrymal  branches  (circumorbital 
pain),  and  pain  down  the  side  of  the  nose  following 
the  nasal  nerve.  Or  the  pain  may  spread  to  the  second 
division  of  the  fifth,  and  discomfort  be  felt  in  the  tem- 
poral region  (orbital  branch  of  second  division),  or  be 
referred  to  the  upper  jaw  and  upper  teeth.  These 
affections  are  associated  also  with  much  lachrymation, 
the  lachrymal  gland  being  also  supplied  through  the 
first  division  of  the  fifth.  Photophobia,  or  intolerance 
of  light,  is  common  in  inflammatory  affections  of  the 
eye.  In  this  condition  there  is  spasm  of  the  orbicular 
muscle,  keeping  the  eye  closed,  or  closing  it  on  the  least 
exposure  to  irritation.  Although  the  orbicular  muscle 
is  supplied  by  the  facial  nerve,  its  fibres  are  derived, 
not  from  the  nucleus  of  the  seventh,  but  from  the 
oculo-motor  nucleus,  situated  near  the  upper  sensory 
nucleus  of  the  fifth,  and  connected  with  it  by  reflex 
paths.  Photophobia  is  most  marked  in  superficial  affec- 
tions of  the  cornea,  and  is  often  much  benefited  by  a 


56  Surgical  Applied  Anatomy,      [chap.  iv. 

seton  in  the  temporal  region.  Inflammation  of  the  iris 
and  glaucoma  are  accompanied  by  hyper-sesthesia  and 
referred  pains  over  the  outer  frontal  and  anterior  tem- 
poral areas  (Head).  The  nerve  centres  for  the  skin  of 
this  region  and  the  eye-ball  are  closely  connected,  a 
relationship  which  may  explain  the  application  of 
counter  irritation  to  the  temples  in  eye  disease.  In- 
flammation of  the  cornea  gives  rise  to  no  referred  pains 
(Head).  Strain  of  the  ciliary  muscle,  which  occurs 
with  errors  of  refraction,  leads  to  referred  pains  and 
areas  of  hyper-sesthesia  over  the  mid  orbital  region  of 
the  forehead.  The  relations  between  the  nasal  nerve 
and  the  orbital  contents  receive  many  illustrations  in 
practice.  Thus,  if  the  front  of  the  nose  be  struck,  or 
the  skin  over  its  lower  part  be  irritated,  as  by  squeezing 
a  painful  boil,  profuse  lachrymation  will  frequently  be 
produced.  Snuff,  too,  by  stimulating  the  nasal  branch 
of  the  ophthalmic  nerve,  often  makes  the  eyes  of  the 
uninitiated  to  water  ;  and  it  is  well  known  that  there  are 
many  disturbances  about  the  nose,  and  the  anterior 
part  of  the  nasal  fossae,  that  can  "  make  the  eyes  water." 
Herpes  zoster  often  provides  a  remarkable  illustration 
of  the  intimate  relation  between  the  nasal  nerve  and  the 
eye.  In  this  affection,  when  the  regions  of  the  supra- 
orbital and  supratrochlear  branches  of  the  first  division 
are  alone  implicated,  the  eye  is  usually  unaffected ;  but 
when  the  eruption  extends  over  the  part  supplied  by  the 
nasal  nerve,  i.e.  runs  down  the  side  of  the  nose,  then 
there  is  very  commonly  some  inflammation  of  the  eye- 
ball. In  frontal  neuralgia  watering  of  the  eye  (irritation 
of  the  lachrymal  branch)  is  very  frequently  met  with. 
The  dangerous  area  ot  the  eye. — Penetrat- 
ing wounds  of  the  cornea  alone,  or  of  the  sclerotic 
alone,  behind  the  ciliary  region,  are  by  no  means  serious  : 
but  wounds  involving  the  ciliary  body,  or  its  immediate 
vicinity,  are  apt  to  assume  the  gravest  characters. 
Inflammation  in  the  ciliary  region  is  peculiarly  obnoxious, 
on  account  of  the  important  vascular  and  nerve  anas- 
tomoses that  take  place  in  the  part.  Indeed,  as  regards 
blood  and  nerve  supply,  there  is  no  more  important 


-Chap,  i  v.i  The  Or  hit  axd  Eye.  57 

'district  in  the  eye-ball.  From  the  ciliary  body  alsu 
inflammations  can  spread,  more  or  less  directly,  to  the 
^cornea,  iris,  choroid,  vitreous,  and  retina.  Plastic,  or 
purulent  inflammation  of  the  ciliary  body,  after  injury, 
is  the  usual  starting  point  of  sympathetic  ophthalmia. 
In  this  terrible  affection  destructive  inflammation  is  set 
lip  in  the  sound  eye,  which  is,  however,  not  usually 
involved  until  two  or  three  months  after  the  other  eye 
has  been  injured.  "  Although  at  present  the  exact 
nature  of  the  process  which  causes  sympathetic  imflamna- 
tion  is  unknown,  and  though  its  path  has  not  been  fully 
traced  out,  it  is  certain  (1)  that  the  change  starts  from 
the  region  most  richly  supplied  by  branches  of  the 
ciliary  nerves,  viz.  the  ciliary  body  and  iris  ;  (2)  that 
its  first  effects  are  generally  seen  in  the  same  part  of 
the  sympathising  eye  ;  (3)  that  the  exciting  eye  has 
nearly  always  been  wounded,  and  in  its  anterior  part ; 
and  that  decided  plastic  inflammation  of  its  uveal  tract 
is  always  present ;  (4)  that  inflammatory  changes  have 
in  some  cases  been  found  in  the  ciliary  nerves  and  optic 
nerve  of  the  exciting  eye "  (Xettleship).  It  Is  now 
generally  believed  that  the  sound  eye  is  directly  infected 
from  the  diseased  one.  The  subarachnoid  spaces  which 
surround  the  optic  nerves  are  in  continuity  at  the 
chiasma,  and  offer  a  path  whereby  infection  may  spread 
from  one  eye  to  the  other. 

The  lens  measures  \  of  an  inch  from  side  to  side, 
and  1  of  an  inch  from  before  backwards.  It,  together 
with  its  capsule,  is  in  all  imrts  perfectly  transparent 
and  perfectly  non-vascular.  The  lens  may  easily  be 
loosened  or  displaced  by  partial  rupture  of  its  suspensory 
ligament,  and  may  find  its  way  into  the  anterior  chamber, 
or,  more  commonly,  back  into  the  vitreous.  The  lens, 
if  disturbed,  may  swell,  and  by  the  pressure  thus  exer- 
cised cause  great  damage  to  the  important  structures 
adjacent  to  it.  The  capsule  is  very  brittle  and  elastic, 
and  when  torn  its  edges  curl  outwards.  It  has  to  be 
lacerated  in  all  cataract  operations,  and  may  be  ruptured 
by  many  forms  of  violence  applied  to  the  eye-ball.  When 
the  capsule  is  wounded   the    aqueous   humour   enters. 


58  Surgical  Applied  Anatomy.      [Chap.  iv. 

and  is  imbibed  by  the  lens  fibres,  which  in  consequence 
swell  up  and  become  opaque,  thus  producing  a  traumatic 
cataract.  In  the  various  forms  of  cataract  the  whole 
lens,  or,  more  commonly,  some  portion  of  it,  becomes 
the  seat  of  opacity.  This  often  commences  in  the  nucleus, 
and  for  a  long  while  remains  limited  to  that  part ;  or  it 
may  first  involve  the  cortex,  and  in  such  a  case  the 
opacity  takes  the  form  of  a  series  of  streaks  that  point 
towards  the  axis  of  the  lens,  and  are  dependent  upon 
the  arrangement  of  the  lens  fibres.  "  In  so-called  '  con- 
cussion cataract,'  where  after  a  blow  on  the  eye  a  part 
of  the  lens  becomes  opaque,  it  appears  probable  that 
the  capsule  has  been  very  slightly  torn  opposite  to  the 
opacity  "  (Lawford). 

Of  the  retina  it  is  only  necessary  to  observe  that 
its  connection  with  the  choroid  is  so  slight  that  it  may 
easily  be  detached  from  that  membrane  by  hsemorrhagic 
or  other  effusions,  and  may  indeed  be  so  detached  b}' 
a  simple  blow  upon  the  globe.  Even  when  extensively 
detached  it  remains,  however,  as  a  rule,  attached  at 
both  the  optic  disc  and  the  ora  serrata.  The  optic 
nerve  as  it  passes  from  the  brain  receives  its  perineural 
sheath  from  the  pia  mater,  and,  in  addition,  two  other 
sheaths  :  an  outer  from  the  dura  mater,  and  an  inner 
from  the  arachnoid.  These  sheaths  remain  distinct 
and  separate,  and  the  two  spaces  enclosed  may  be 
injected,  the  outer  from  the  subdural,  the  inner  from 
the  subarachnoid  spice.  Thus  inflammatory  affections 
of  the  cerebral  meninges  can  readily  extend  along  the 
optic  nerve  to  the  optic  disc  through  these  spaces  in 
the  nerve  sheath,  while  in  cases  of  intracranial  disease 
other  than  meningeal,  the  mischief  may  extsnd  from 
the  brain  to  the  disc  along  the  interstitial  connective 
tissue  in  the  nerve.  These  connections  may  serve  in 
part  to  explain  the  frequent  association  of  optic  neuritis 
with  intracranial  disease.  Optic  neuritis  usually  implies 
that  the  optic  disc  or  papilla  is  inflamed,  but  in  excep- 
tional cases  the  changes  are  limited  to  that  part  of  the 
nerve  behind  the  globe  (retro-bulbar  neuritis).  The  length 
of  the  optic  nerve  within  the  orbit  is  28  to  29  mm. 


Chap.  IV.] 


The  Orbit  and  Eve. 


59 


The  aqueous  and  vitreous  humours.— The 

aqueous  fills  the  space  between  the  capsule  and  suspensory 
ligament  of  the  lens  and  the  cornea.  The  iris  divides 
this  space  into  two  parts,  the  anterior  and  posterior 
chambers.  Since,  however,  the  iris  is  largely  in  actual 
contact  with 
the  lens,  it 
happens  that 
the  posterior 
chamber  is  re- 
presented by  a 
little  angular 
interval  be- 
tween the  iris, 
the  ciliary  pro- 
cesses, and  the 
suspensory 
ligament  of  the 
lens  (Fig.  11). 
The  depth  of 
the  anterior 
chamber  is 
3 '6  mm.  The 
cornea  at  its 
circumference 
breaks  up  into 
bundles  of 
fibres,  which 
are  partly  con- 
tinued into  the 
front  of  the  iris, 
and  which  con- 
stitute the  ligamentum  pectinatum  iridis.  Between 
the  processes  of  this  ligament  there  are  intervals 
which  lead  into  certain  cavernous  spaces  called  the 
spaces  of  Fontana.  These  spaces  in  their  turn  com- 
municate with  a  large  circular  canal  situate  in 
the  sclerotic  close  to  its  junction  with  the  cornea,  and 
known  as  the  canal  of  Schlemm.  Tins  space  is  in 
communication    with    the    veins   of   the  anterior    part 


Fig-.  1  J. —Section  of  Globp,   showing  Iris,   Lens, 
Ciliary  Region,  etc.     (After  Allen  Thomson.) 

a.  Cornea  :  b,  Fcleroiic  ;  c,  lens  :  r?,  iris  :  c,  ciliary  pro- 
ess  ;  /,  conjunctiva  ;  if,  canal  of  Seblemm  ;  h.  canal 
of  iviir;  i, anterior  margin  of  vitreous  humour;  j, 
choroid  covered  by  retina  ;  k,  aqueous  chamber- 


60  Surgical  Applied  Anatomy.      [Chap. iv. 

of  the  sclerotic,*  and  thus  through  this  somewhat 
complicated  channel  the  aqueous  chamber  is  brought 
into  relation  with  the  venous  circulation.  This  relation 
probably  explains  the  ready  absorptive  powers  of  the 
aqueous.  Thus,  if  pus  finds  its  way  into  the  anterior 
chamber  (hypopyon)  it  is  usually  readily  absorbed. 
The  same  applies  to  moderate  extravasations  of  blood 
in  the  chamber,  and  the  speedy  removal  of  such  effusions 
contrasts  with  the  difficulty  that  is  experienced  in  the 
absorption  of  blood  from  the  vitreous  chamber.  The 
treatment  of  soft  cataracts  by  the  "  needle  operation  " 
depends  for  its  success  upon  the  absorptive  powers  of 
the  aqueous.  In  this  procedure,  the  lens  capsule  having 
been  torn  tb rough,  and  the  cataract  broken  up  with 
needles,  the  removal  of  the  opaque  debris  is  left  to  the 
aqueous,  and  it  is  not  long  before  its  efficacy  in  that 
direction  is  seen. 

The  vitreous  takes  little  active  share  in  ocular 
maladies.  It  may  be  secondarily  affected  in  inflamma- 
tion of  adjacent  parts,  may  be  the  seat  of  haemorrhages, 
and  is  often  occupied  by  opaque  bodies  of  various  kinds. 
Foreign  bodies  have  lodged  in  the  vitreous  for  con- 
siderable periods  without  causing  any  symptoms.  The 
muscae  volitantes  that  so  often  trouble  the  myopic  are 
due  to  little  opaque  matters  in  the  vitreous,  and  very 
often  have  exactly  the  appearance  that  the  corpuscles 
of  the  vitreous  present  when  seen  under  the  microscope, 

The  vitreous  is  readily  separated  from  the  retina 
except  behind,  opposite  the  disc  where  the  artery  to 
the  lens  enters  in  the  foetus, 

This  vessel  is  a  branch  of  the  central  artery  of  the 
retina,  and  may  persist  as  a  fibrous  cord  in  adult  life. 
In  some  rare  cases  it  has  continued  to  transmit  blood, 
and  in  such  instances  its  pulsation  can  be  seen  by  the 
ophthalmoscope. 

Glaucoma  is  a  disease  the  symptoms  of  which  are 

*  The  j>recise  manner  in  which  these  spaces  communicate  with 
the  neighbouring  veins  has  not  been  demonstrated  histologically. 
The  statement  is  founded  mainly  upon  the  experiments  of 
Schwalbe. 


Chap,  iv.]  The  Orbit  and  Eve.  6i 

all  dependent  upon  an  increase  in  the  intraocular  tension 
of  the  globe.  The  increased  tension  is  due  to  an  excess 
of  fluid  within  the  eye-ball,  and  this  would  appear  to 
be  due  to  certain  changes,  seldom  absent  in  the  glauco- 
matous, that  interfere  with  the  normal  escape  of  this 
fluid.  Normally  there  is  a  constant  movement  of  fluid 
from  the  vitreous  through  the  suspensory  ligament 
into  the  posterior  chamber,  and  thence  round  the 
pupillary  margin  of  the  iris  to  the  anterior  chamber. 
This  fluid  is  derived  mainly  from  the  ciliary  body,  and 
in  a  less  degree  from  the  posterior  surface  of  the  iris. 
Atrophy  of  the  epithelium  on  the  ciliary  body  is  said 
to  lead  to  diminished  tension.  From  the  anterior 
chamber  the  fluid  can  escape  into  the  veins  through 
the  gaps  in  the  ligament um  pectinatum  already  alluded" 
to  (Fig.  11).  It  is  remarkable  that  in  nearly  every 
case  of  glaucoma  these  gaps  are  occluded  by  the  complete 
obliteration  of  the  angle  between  the  periphery  of  the 
iris  and  the  cornea,  which  angle  is  normally  occupied 
by  the  ligamentum  pectinatum.  The  importance  of 
the  peripheral  part  of  the  anterior  chamber  in  relation 
to  the  outflow  of  fluid  from  the  eye  is  shown  in  many 
ways.  If  this  part  be  blocked  by  the  iris  in  perforation 
of  the  cornea,  or  by  the  lens  in  some  dislocations  of 
that  body,  increased  tension  of  the  globe  is  apt  to  follow. 
A  like  increase  of  tension  is  said  to  attend  the  appli- 
cation of  the  actual  cautery  to  the  sclero-corneal  margin 
and  some  cases  of  episcleritis.  Dr.  Brailey  believes  that 
some  outflow  also  takes  place  along  the  optic  nerve. 
It  is  well  known  that  pressure  upon  that  nerve  may 
produce  oedema  of  the  disc.  The  relief  given  to  glaucoma 
by  iridectomy  appears  to  depend  upon  the  circumstances 
that  the  operation  practically  opens  up  again  these 
channels  of  communication  from  the  aqueous,  since 
the  procedure,  to  be  successful,  should  involve  an  incision 
so  far  back  on  the  sclerotic  as  to  fully  pass  through 
the  angle  just  alluded  to.  It  is  needful  also  that  the 
iris  should  be  removed  quite  up  to  its  attachment,  and 
that  the  portion  resected  should  be  considerable.  The 
symptoms  of  glaucoma  are.  all  explained  by  the  effects 


62  Surgical  Applied  Anatomy.      [Chap,  rv. 

of  the  abnormal  tension.  Thus,  the  ciliary  nerves  are 
compressed  against  the  unyielding  sclerotic,  and  give 
rise  to  intense  pain,  while  the  disturbance  in  their 
functions  shows  itself  in  the  fixed  and  dilated  pupil 
and  in  the  anaesthetic  cornea.  Perhaps  the  first  parts 
to  suffer  from  compression  are  the  retinal  blood-vessels, 
and  the  effect  upon  them  will  be  most  obvious  at  the 
periphery  of  the  retina,  i.e.  at  the  extreme  limit  of 
the  retinal  circulation.  Hence  follows  that  gradual 
narrowing  of  the  visual  field  which  is  constant  in  glau- 
coma, while  the  pressure  upon  the  optic  nerve  produces 
those  flashes  of  light  and  other  spectra  which  occur 
in  the  disease.  The  weakest  part  of  the  sclerotic  is  at  the 
disc  at  the  lamina  cribrosa.  This  part  rapidly  yields 
under  the  pressure,  and  so  produces  the  "  glaucomatous 
cup."  Pressure  in  the  opposite  direction  pushes  the 
lens  forward,  and  thus  narrows  the  anterior  chamber ; 
while  the  general  interference  with  the  ocular  circulation 
is  shown  in  the  distended  vessels  that  appear  upon  the 
glob3. 

The  eyelids.— The  skin  over  the  eyelids  is  extremely 
thin  and  delicate,  and  shows  readily  through  its  sub- 
stance any  extravasation  of  blood  that  may  form  beneath 
it.  Its  laxity,  moreover,  renders  it  very  well  adapted 
for  certain  plastic  operations  that  are  performed  upon 
the  part.  Its  loose  attachments  cause  it  to  be  readily 
influenced  by  traction,  and  the  shrinking  of  cicatrices 
below  the  lower  lid  is  very  apt  to  draw  that  fold  away 
from  the  globe,  and  so  produce  the  condition  of  eversion 
of  the  lid  known  as  ectropion.  The  contraction  of  the 
conjunctiva  after  inflammatory  conditions,  or  after  it 
has  been  subjected  to  destructive  agencies,  is  prone, 
on  the  other  hand,  to  curl  either  lid  inwards  towards 
the  globe,  and  thus  to  produce  entropion.  The  lids 
present  many  transverse  folds  ;  one  of  these  on  the 
upper  lid,  deeper  and  more  marked  than  the  rest,  divides 
the  lid  into  two  parts,  the  part  below  being  that  which 
covers  the  globe,  the  part  above  being  that  in  relation 
with  the  soft  structures  of  the  orbit.  In  emaciation 
the  lid  becomes  much  sunken  in  the  line  of  this  fold. 


Chap.  IV.] 


The  Orbit  and  Eve. 


63 


I 


&. 


B6 


JU 


Incisions  should  follow  the  direction  of  these  folds.  The 
lids  are  very  freely  supplied  with  blood,  and  are  often 
the  seat  of  naevi  and  other  vascular  growths.  Rodent 
ulcer  so  frequently  at- 
tacks this  part  that  it 
was  originally  known  as 
"  Jacob's  ulcer  of  the 
eyelid." 

The  following  layers 
are  found  in  either  lid  in 
order  :  (1)  The  skin  ;  (2) 
the  subcutaneous  tissue ; 
(3)  the  orbicularis  palpe- 
brarum ;  (4)  the  tarsal 
cartilage  and  ligament  ; 
(5)  the  layer  of  Meibo- 
mian glands  ;  and  (6) 
the  conjunctiva.  In  the 
upper  lid  the  levator 
palpebral  is  found  pass- 
ing to  the  tarsal  cartilage. 
The  subcutaneous  tissue 
is  very  lax,  and  hence  the 
lids  swell  greatly  when 
cbdematous,  or  when  in- 
flamed, and  when  the 
seat  of  haemorrhage.  On 
this  account  it  is  inad- 
visable to  apply  leeches 
to  the  lids,  on  account 
of  the  extensive  "  black 
eye "  that  may  follow. 
This  tissue  is  peculiar 
in  containing  no  fat.  At 
the  edge  of  the  lids  are 
found  the  eyelashes,  the 

orifices  of  the  Meibomian  glands,  and  of  some  modified 
sweat  and  sebaceous  glands.  This  edge,  like  other  points 
of  junction  of  skin  and  mucous  membrane,  is  apt  to  be 
the  seat  of  irritative  affections.     Being  a  free  be  .'der  also, 


I 

I 


;'<(^£s_    ,      { MOS 


7i£T.     12—  Vertical    Section    through 
Upper  Eyelid.    (After  Waldeyer.) 

1,  Skin  ;  b,  orbicularis  ;  &',  its  ciliary  part ; 
r,  involuntary  muscle  of  eyelid  ;  d,  con- 
junctiva; e.  tarsal  cartilage;/,  Meibo- 
mian gland;  g,  modified  sweat  gland  ; 
It,  eyelashes  ;  i,  post  tarsal  glands. 


64  Surgical  Applied  Anatomy.      fOiap.  rv, 

the  circulation  is  terminal,  and  stagnation  in  the  blood 
current  is  not  difficult  to  produce.  Sycosis,  an  inflamma- 
tion involving  the  hair  follicles  and  some  of  the  glands 
at  the  edge  of  the  lid,  is  among  the  most  common  of 
ophthalmic  affections.  The  common  stye  also  is  a  sup- 
puration in  the  connective  tissue  or  in  one  of  the  glands 
at  the  margin.  On  everting  the  lid  the  Meibomian 
glands  can  be  seen  through  the  conjunctiva  as  lines  of 
yellowish  granules.  The  common  tarsal  cyst  is  a  reten- 
tion cyst  developed  in  one  of  these  glands. 

Two  arteries  supply  either  lid  :  a  palpebral  branch 
of  the  ophthalmic  running  along  the  inner  part  of  each 
lid,  and  a  branch  of  the  lachrymal  along  the  outer  part 
of  each  lid.  Four  nerves  supply  the  upper  eyelid,  the 
supraorbital,  the  supra-  and  infra-trochlear,  and  the 
lachrymal.  One  nerve  supplies  the  lower  lid,  the  infra- 
orbital. Some  of  the  lymphatics  of  the  eyelids  enter 
the  pre-auricular  glands,  hence  in  cases  of  chancre  of  the 
lid  the  glandular  enlargement  has  nearly  always  been 
noticed  in  front  of  the  parotid  gland  (Fig.  21,  p.  164). 

The  conjunctiva.— The  ocular  part  of  this  mem- 
brane is  thin,  very  loosely  attached,  and  not  very 
extensively  supplied  with  blood  ;  the  palpebral  portion 
is  thicker,  more  closely  adherent,  and  more  vascular. 
At  the  edge  of  the  cornea  the  conjunctiva  becomes 
continuous  with  the  epithelium  covering  that  tunic. 
The  looseness  of  the  ocular  conjunctiva  allows  it  to  be 
freely  moved  about,  and  is  of  great  value  in  some  opera- 
tions :  as,  for  example,  in  Teale's  operation  for  sym- 
blepharon,  where  a  bridge  of  conjunctiva,  dissected  up 
from  the  globe  above  the  cornea,  is  drawn  down  over 
the  cornea  to  cover  a  raw  surface  in  contact  with  the 
lower  lid.  This  lax  tissue  favours  the  development 
of  oedema  (chemosis),  which  in  extreme  cases  may  reach 
such  a  degree  that  the  patient  cannot  close  his  eye. 
The  vessels  also,  being  feebly  supported,  are  prone  to' 
give  way  under  no  great  provocation.  Thus,  subcon- 
junctival h&emorrhages  may  occur  from  severe  vomiting, 
or  during  a  paroxysm  of  whooping  cough.  Blood 
also  may  find  its  way  beneath  the  membrane  in  fractures 


chap,  iv.]  The  Orbit  and  Eye.  65 

of  the  base  of  the  skull.  Haemorrhages  beneath  the 
membrane  arc  unlike  other  extravasations  (bruises),  in 
that  they  retain  their  scarlet  colour.  This  is  clue  to 
the  fact  that  the  thinness  of  the  conjunctiva  allows 
oxygen  to  reach  the  blood  and  retain  for  it  an  arterial 
character.  Severe  inflammation  of  the  conjunctiva 
may  lead  to  considerable  cicatricial  changes,  as  is  the 
case  in  other  mucous  membranes,  and  especially,  perhaps, 
in  the  urethra.  The  contraction  of  the  conjunctiva 
after  destructive  processes  is  apt  to  lead  to  entropion. 
If  both  the  ocular  and  the  corresponding  part  of  the 
palpebral  conjunctiva  have  been  destroyed,  the  two 
raw  surfaces  left  will  readily  adhere  ;  the  lid  will  become 
fused  to  the  globe,  and  the  condition  called  symblepharon 
be  produced.  This  condition  concerns  the  lower  lid, 
and  is  generally  brought  about  by  lime  or  other  caustics 
being  accidentally  introduced  between  the  under  lid 
and  the  globe. 

In  one  common  form  of  inflammation  of  this 
membrane  a  number  of  little  "granulations"  appear 
upon  the  palpebral  conjunctiva.  These  are  not  real 
granulations,  since  no  true  ulceration  of  the  part  takes 
place,  hut  they  appear  to  be  made  up,  some  of  nodules 
of  adenoid  tissue,  others  of  enlarged  mucous  follicles 
and  of  hypertrophicd  papillae,  all  of  which  structures 
are  normally  found  in  the  membrane.  The  condition 
is  known  as  "  granular  lids,"  and  is  associated  with  the 
formation  of  much  new  tissue  in  the  deeper  parts  of 
the  membrane.  From  the  absorption  of  this  new 
tissue  and  of  these  granulations  a  contracting  cicatrix 
results,  leading  to  much  puckering  of  the  membrane, 
and  often  to  entropion  and  inversion  of  the  eyelashes. 
In  purulent  ophthalmia  the  cornea  is  in  great  risk  of 
destruction,  owing  to  the  strangulation  of  its  vessels, 
and  to  the  effects  possibly  of  the  discharge  directly 
upon  the  membrane. 

The  lachrymal  apparatus.— The  lachrymal 
gland  is  invested  by  a  special  fascia  which  separates 
it  from  the  general  cavity  of  the  orbit  ;  and,  according 
to  Tillaux,   this  little   body  can   be   removed   without 


66 


Surgical  Applied  Anatomy.     [Chap.  iv. 


opening  the  greater  space  of  the  orbit.  The  gland 
may  inflame,  and  become  so  enlarged  as  to  appear  as 
a  tumour,  which  may  displace  the  globe  downwards 
and  inwards,  and  press  forwards  the  oculo-palpebral 
fold  of  conjunctiva.     If  an  abscess  forms,  it  most  usually 


fron.  SINUS. 
ROOF, 


INFUNDIBULUM. 


SAC 


FOLD. 

MIDDLE  TURB.  PROG 
NASAL  DUCT. 


=-VALVE. 


SEPTUM. 

INF.   TURB.  PRO& 


Fig.  13. — Vertical  Section  at  the  Root  of  the  Nose  to  expose  the  Nasal  Duct. 

{After  Merkel.) 

The  outline  of  the  frontal  sinus,  with  its  duct,  the  infundibuluni,  is  indicated. 
Tlie  position  of  the  upper  and  lower  lachrymal  canaliculi  is  shown  (ab). 


breaks  through  the  skin  of  the  upper  lid.  Cysts  of 
the  gland  (dacryops)  are  due  to  obstruction  and 
distension  of  some  of  its  ducts. 

The  lachrymal  sac  is  situated  at  the  side  of  the  nose, 
near  the  inner  canthus,  and  lies  in  a  groove  on  the 
lachrymal  and  superior  maxillary  bones  (Fig.  13).  On 
its  outer  side,  and  a  little  anteriorly,  it  receives  the 
lachrymal  canals.  In  front  of  the  sac  is  the  tendo  oculi. 
If  the  two  lids  be  forcibly  drawn  outwards  this  tendon 
can  be  readily  felt  and  seen,  and  is  the  great  guide  to 
the  sac.    It  can  also  be  felt  as  it  is  tightened,  when 


chap,  iv.]  The  Orbit  and  Eye.  67 

the  lids  are  firmly  closed.  It  crosses  the  sac  at  right 
angles,  and  at  about  the  junction  of  its  upper  third 
with  its  lower  two-thirds.  A  knife  entered  immediately 
below  the  tendon  would  about  open  the  middle  of  the 
sac,  and  it  may  be  noted  that  a  lachrymal  abscess,  when 
about  to  discharge,  always  points  below  the  tendon. 
Epiphora,  or  overflow  of  tears,  is  due  in  the  main  to 
two  causes  :  (1)  To  an  obstruction  in  any  part  of  the 
lachrymal  passages  from  the  puncta  to  the  opening 
of  the  nasal  duct  in  the  nose  ;  (2)  to  any  cause  that 
removes  the  lower  punctum  from  its  contact  with  the 
globe,  as  may  be  the  case  in  ectropion,  in  entropion, 
in  swelling  of  the  lower  lid,  etc.  Facial  palsy  causes 
epiphora,  because,  the  orbicular  muscle  being  relaxed, 
the  punctum  falls  away  from  the  globe,  and,  moreover, 
the  passage  of  the  tears  is  no  longer  aided  by  the  suction 
action  effected  by  the  muscle  in  the  process  of  winking. 
The  canaliculi  may  readily  be  slit  up  by  a  proper  knife, 
atid  a  probe  can  without  difficulty  be  passed  down 
the  nasal  duct  from  the  lachrymal  sac.  The  duct  is 
a  little  over  half  an  inch  in  length,  and  the  probe  that 
traverses  it  should  pass  downwards,  and  a  little  back- 
wards and  outwards.  The  nasal  duct  perforates  the 
mucous  membrane  of  the  nose  below  the  inferior  turbinate 
process  very  obliquely,  so  that  its  inner  wall  acts  as  a 
valve.  If  this  is  destroyed  by  ulceration,  as  sometimes 
occurs  in  syphilis,  the  lachrymal  sac  may  be  inflated 
by  blowing  the  nose.  In  the  upper  part  of  the  duct 
the  mucous  membrane  is  thrown  into  a  spiral  fold, 
which,  after  inflammatory  conditions,  may  give  rise 
to  stricture  (Fig.  13). 

As  affections  of  the  lachrymal  sac  are  often  very 
painful,  it  may  be  noted  that  the  nerve  supply  of  the 
sac  is  derived  from  the  infratrochlear  branch  of  the 
nasal  nerve. 


68 


CHAPTER     V. 

THE    EAE. 

The  pinna  and  external  auditory  meatus. 

— The  pinna  may  be  congenitally  absent,  or  may  be 
supplemented  by  supernumerary  portions  of  the  auricle, 
which  may  be  situated  upon  the  cheek  or  side  of  the  neck. 
In  the  latter  situation  the  so-called  supernumerary 
auricle  consists  in  an  irregular  leaf  of  fibro-cartilage 
developed  from  the  margins  of  one  of  the  lower  branchial 
clefts.  (See  page  166.)  The  tag-like  supernumerary 
auricles  that  are  found  on  the  cheek  just  in  front  of  the 
pinna  or  meatus  are  due  to  the  irregular  development 
or  want  of  fusion  of  one  or  more  of  the  six  tubercles 
from  which  the  pinna  itself  is  developed.  The  pinna 
may  present  a  congenital  fistula.  This  may  be  due 
to  a  defective  closure  of  the  first  branchial  cleft.  This 
cleft  is  represented  in  the  normal  ear  by  the  Eustachian 
tube,  the  tympanum,  and  the  external  auditory  meatus, 
the  pinna  being  developed  from  the  integument  behind 
the  cleft.  In  these  congenital  fistuke,  when  well  marked, 
the  pinna  is  cleft  just  in  front  of  the  tragus,  or  through 
the  helix,  and  there- is  more  or  less  failure  in  the  closing 
of  the  meatus  and  tympanum,  while  the  membrana 
tympani  will  be  more  or  less  deficient  or  entirely  absent. 
In  other  cases  the  "  fistula "  appears  merely  as  a 
narrow  sinus  or  a  depression,  running  through  the 
helix.  Some  of  the  smaller  and  more  superficial  fistulas 
are  due  not  to  a  defective  closure  of  the  branchial  cleft 
but  to  want  of  complete  fusion  between  certain  of  the 
tubercles  from  which  the  pinna  is  primarily  developed. 
Accidental  removal  of  the  pinna  is  usually  associated 
with  but  comparatively  little  diminution  in  the  acuteness 
of  hearing. 

The  skin  covering  the  auricle  is  thin  and  closely 
adherent.  The  subcutaneous  tissue  is  scanty,  and  con- 
tains but  very  little  fat.  In  inflammatory  conditions 
of  the  surface,  such  as  erysipelas,  the  pinna  may  become 


Chap,  v.]  The  Ear.  69 

extremely   swollen   and   very   great   pain   be   produced 
from  the  tenseness  of  the  parts.     The  pinna  and  carti- 
laginous meatus  are  very  firmly  attached  to  the  skull 
so  that  the  body,  if  not  of  great  weight,  may  be  lifted 
from  the  ground  by  the  ears. 

In  chronic  gout,  little  deposits  of  urate  of  soda  (called 
tophi)  are  often  met  with  in  the  pinna,  and  are  usually 
placed  in  the  subcutaneous  tissue  at  the  edge  of  the 
helix.  M.  Paul  has  pointed  out  that,  when  ear-rings 
are  worn,  the  usual  hole  made  by  the  ring  may  become 
converted  into  a  vertical  slit,  or  the  ear-ring  may  cut 
its  way  out,  leaving  a  slit  in  the  lobule.  This  it  may  do 
several  times  if  re-applied,  thus  producing  many  slits 
in  the  same  lobule.  He  considers  such  conditions  as 
absolutely  diagnostic  of  scrofula.  * 

The  external  auditory  meatus  is  about  \\ 
inches  long.  It  is  directed  forwards  and  inwards,  having 
the  same  direction  as  the  petrous  bone.  The  external 
meatus,  the  promontory,  the  cochlea,  and  the  internal 
meatus  lie  nearly  in  the  same  line.  The  canal  has  a 
vertical  curve  about  its  middle,  with  the  convexity 
upwards.  To  straighten  the  canal  for  the  introduction 
of  specula  and  other  instruments,  the  pinna  should  be 
drawn  upwards  and  a  little  outwards  and  backwards. 
The  osseous  part  forms  a  little  more  than  one-half  of  the 
tube,  and  is  narrower  than  the  cartilaginous  part. 

In  the  infant  at  one  year,  a  third  only  of  the  meatus 
is  formed  of  bone.  The  rest  is  cartilaginous.  In  a 
child  of  five  or  six  years  of  age  the  bony  and  cartilaginous 
portions  of  the  meatus  are  about  of  the  same  length 
(Symington).  The  meatus  is  relatively  as  long  in  a 
child  as  it  is  in  an  adult.  The  narrowest  portion  of  the 
meatus  is  about  its  middle.  The  outer  orifice  is  ellip- 
tical, with  its  greatest  diameter  directed  from  above 
downwards  ;  therefore  specula  should  be  elliptical  in 
shape  rather  than  round.  The  inner  end  of  the  tube, 
on  the  other  hand,  is  slightly  wider  in  the  transverse 
direction.     Owing  to  the  obliquity  of  the   membrana 

*  See  "Scrofula   and   its   Gland   Diseases,"    by    the   Author. 
Lond.     1882. 


7o 


Surgical  Applied  Anatomy 


[Chap.  v. 


tympani,  the  floor  of  the  meatus  is  longer  than  the  roof. 
The  cartilaginous  segment  of  the  tube  presents  many 
sebaceous  glands  that  may  be  the  seat  of  minute  and 
very  painful  abscesses.  It  also  presents  numerous 
ceruminous  glands,  which  secrete  the  cerumen  of  the 
ear,  and  which,  when  their  secretion  is  excessive,  may 
produce  the  plugs  of  wax  that  often  block  the  meatus. 
Lacerated  wounds  of  the  cartilaginous  meatus  are  apt 
to  bleed  freely,  owing  to  the  difficulty  with  which  the 
vessels  bound  up  with  the  cartilage  contract.  In  the 
floor  of  this  part  of  the  meatus  are  certain  fissures, 
fissures  of  Santorini.  They  are  filled  up  with  fibrous 
tissue.     They  permit  of  easier  movement  of  the  carti- 


[Fig.   14.— Section  through  the  External  Meatus,   Middle  Ear,  and 
;  Eustachian  Tube  (Tillaux). 

a,  External  auditory  meatus  ;  b,  attic  of  tympanum  ;  c.  Eustachian  tulie  ; 
rf,  internal  auditory  meatus  ;  e,  cochiea;  /,  ossicles j  g,  membrana  tympani; 
h,  styloid  process. 


chap,  v.]  The  Ear.  7 1 

laginous  meatus.  It  is  through  these  gaps  in  the  cartilage 
that  a  parotid  abscess  may  burst  into  the  meatus.  There 
are  neither  hairs  nor  glands  in  the  lining  of  the  bony 
part  of  the  tube. 

The  skin  of  the  meatus,  when  inflamed,  may  pro- 
duce an  extensive  muco-purulent  discharge,  otitis  ex- 
terna. Polypi  are  apt  to  grow  from  the  soft  parts  of 
the  canal,  and  exostoses  from  its  bony -wall.  Foreign 
bodies  are  frequently  lodged  in  the  meatus,  and  often 
involve  great  difficulties  in  their  extraction.  It  would 
appear  that  in  many  cases  more  damage  is  done  by  the 
surgeon  than  by  the  intruding  substance.  Mason 
reports  three  cases  where  a  piece  of  slate-pencil,  a  cherry- 
stone, and  a  piece  of  cedar-wood  were  lodged  in  the  canal 
for  respectively  forty  years,  sixty  years,  and  thirty 
years. 

The  upper  vtaR  of  the  meatus  is  in  relation  with  the 
cranial  cavity,  from  which  it  is  only  separated  by  a  dense 
layer  of  bone.  Thus,  abscess  or  bone  disease  in  this  part 
may  possibly  lead  to  meningitis.  A  case  is  reported 
where  an  inflammation  of  the  cerebral  membrane  fol- 
lowed upon  the  retention  of  a  bean  within  the  meatus. 
The  anterior  wall  of  the  canal  is  in  relation  with  the 
temporo-maxillary  joint  and  with  part  of  the  parotid 
gland.  This  may  serve  in  one  way  to  explain  the  pain 
often  felt  in  moving  the  jaw  when  the  meatus  is  inflamed, 
although,  at  the  same  time,  it  must  be  remembered 
that  movement  of  the  lower  maxilla  produces  a  move- 
ment in  the  cartilaginous  meatus,  and  that  both  the 
canal  and  the  joint  are  supplied  by  the  same  nerve  (the 
auriculo-temporal).  From  its  relation  to  the  condyle 
of  the  jaw,  it  follows  that  this  wall  of  the  meatus  has  been 
fractured  by  that  condyle  in  falls  upon  the  chin.  Tillaux 
states  that  abscess  in  the  parotid  gland  may  spread 
into  the  meatus  through  the  anterior  wall  of  the  passage. 
The  posterior  wall  separates  the  meatus  from  the  mastoid 
cells,  and  through  this  partition  inflammation  may 
extend  from  one  part  to  the  other,  especially  as  the 
cartilage  of  the  tube  is  deficient  at  its  upper  and  posterior 
parts.     Directly  behind  the  posterior  wall  is  the  lateral 


"]2  Surgical  Applied  Anatomy.       [Chap.  v. 

sinus.  The  inferior  wall  of  the  bony  meatus  is  very 
dense  and  substantial,  and  corresponds  to  the  vaginal 
and  styloid  processes. 

Blood  supply. — The  pinna  and  external  meatus 
are  well  supplied  with  blood  by  the  temporal  and 
posterior  auricular  arteries,  the  meatus  receiving  also 
a  branch  from  the  internal  maxillary.  In  spite  of 
this  supply,  the  pinna  is  frequently  the  seat  of  gangrene 
from  frost-bite.  This  is  due  to  the  fact  that  all  the 
vessels  are  superficial  and  are  close  beneath  the  surface, 
that  the  part  is  much  exposed  to  cold,  and  that  the  pinna 
lacks  the  protection  of  a  covering  of  fat.  The  same 
conditions  predispose  to  gangrene  of  the  nose  from 
external  cold.  Bloody  tumours  (hsematomata)  are 
often  met  with  on  the  pinna,  and  are  said  to  be  more 
common  in  lunatics.  They  appear  to  be  frequently 
due  to  injury,  and  to  consist  of  an  extravasation  between 
the  perichondrium  and  the  cartilage. 

Nerve  supply. —The  outer  surface  of  the  pinna 
is  supplied  by  the  auriculo-temporal  nerve,  with  the 
exception  of  the  skin  over  the  antitragus,  the  vertical 
part  of  the  antihelix,  the  corresponding  part  of  the 
helix  and  its  fossa,  and  the  lobule,  which  parts  are 
all  supplied  by  the  great  auricular  nerve.  The  inner 
surface  is  almost  entirely  supplied  by  the  latter  nerve, 
the  small  occipital  nerve  giving  a  branch  to  the  upper 
extremity,  and  Arnold's  nerve  a  branch  to  the  back  of 
the  concha,  near  the  mastoid  process.  The  meatus  is 
supplied  mainly  by  the  auriculo-temporal,  with,  in 
addition,  a  contribution  from  Arnold's  nerve,  which 
goes  to  the  lower  and  back  part  of  the  canal,  not  far 
from  its  commencement.  Arnold's  nerve,  a  little  branch 
from  the  pneumo-gastric,  has  been  credited  with  a  good 
deal  in  connection  with  the  nerve  relations  of  the  ear. 
After  a  heavy  dinner,  when  the  rose-water  comes  round, 
it  is  common  to  see  the  more  experienced  of  the  diners 
touch  the  lower  part  of  the  back  of  the  ear  with  the 
moistened  serviette.  This  is  said  to  be  very  refreshing, 
and  is  supposed  to  prove  to  be  an  unconscious  stimula- 
tion of  Arnold's  nerve,  a  nerve  whose  main  trunk  goes 


Chap,  v.]  The  Ear.  73 

to  the   stomach.     Hence,   this   little   branch  has   been 
facetiously  termed  "  the  alderman's  nerve." 

Ear  coughing,  ear  sneezing,  ear  yawning. 

— It  is  not  uncommon  to  have  a  troublesome  dry  cough 
associated  with  some  mischief  in  the  meatus.  Sometimes 
the  mere  introduction  of  a  speculum  will  make  the 
patient  cough.  A  case  is  reported,  where  a  troublesome 
cough  persisted  for  eighteen  months,  and  at  once  ceased 
on  the  removal  of  a  plug  of  wax  from  the  ear.  In  snch 
cases  the  irritation  is  conveyed  to  the  respiratory  and 
cough  centres  in  the  floor  of  the  fourth  ventricle  by 
Arnold's  nerve,  a  small  branch  of  the  vagus.  Gaskell 
has  shown  that  the  vagus  also  contains  the  disassociated 
visceral  fibres  of  the  fifth  nerve.  Hence,  disturbances 
may  be  set  up  in  the  vagal  nuclei  through  branches  of 
the  fifth  nerve,  such  as  the  auriculotemporal.-  The 
connection  of  the  nerves  of  the  external  auditory  meatus 
with  the  vagal  nuclei  also  explains  the  sneezing  or  vomit- 
ing which  is  sometimes  caused  by  the  presence  of 
foreign  bodies  in  the  external  meatus.  The  same  nerve 
connection  also  explains  the  occurrence  of  repeated 
yawning,  sometimes  set  up  by  ear  ailments.  Irritation 
eonveyed  along  the  inferior  dental  or  lingual  nerves 
may  be  referred  along  the  auriculotemporal.  Hence  the 
need  to  examine  the  tongue  and  lower  teeth  in  cases  of 
earache.  Head  has  pointed  out  that  disease  of  the  ear, 
the  tonsil,  the  tongue  or  the  lower  jaw  may  be  associated 
with  an  area  of  tenderness  in  the  skin  along  and  below 
the  jaw. 

It  is  a  common  practice  to  introduce  ear-rings,  with 
the  idea  of  relieving  obstinate  affections  of  the  eye.  No 
anatomical  basis  can  be  offered  to  explain  such  treatment. 
The  lobule  is  supplied  by  the  great  auricular  nerve  which 
springs  from  the  second  and  third  cervical  nerves,  while 
the  eye  is  supplied  by  the  ophthalmic  division  of  the 
fifth.  The  lower  sensory  nucleus  of  the  fifth  is  a  direct 
continuation  upwards  of  the  grey  matter  from  which 
the  posterior  roots  of  the  cervical  nerves  arise. 

Hilton  reports  a  case  of  obscure  pain  in  the  ear  which 
was  found  to  be  due  to  an  enlarged  gland  in  the  neck, 


74  Surgical  Applied  Anatomy.       [Chap.  v. 

that  pressed  upon  the  trunk  of  the  great  auricular 
nerve. 

Memlirana  tympani.— This  membrane  is  very 
obliquely  placed,  forming  with  the  horizon  an  angle 
of  45°.  At  birth  it  appears  to  be  more  nearly  hori- 
zontal, although  it  is  not  really  so.  In  cretins,  and 
in  some  idiots,  it  is  said  to  retain  this  apparent  inclination. 
Owing  to  the  sloping  downwards  of  the  bony  wall  of  the 
meatus  at  its  inner  end,  that  wall  forms  with  the  lower 
edge  of  the  membrane  a  kind  of  sinus  in  which  small 
foreign  bodies  may  readily  lodge  (Fig.  14).  The  ring 
of  bone  to  which  the  membrane  is  attached  is  deficient 
at  its  upper  and  anterior  part.  The  gap  so  formed 
is  called  the  notch  of  Rivini,  and  is  occupied  by  loose 
connective  tissue,  covered  by  a  continuation  of  the 
lining  of  the  meatus,  and  through  it  pus  may  escape 
from  the  middle  ear  into  the  auditory  canal  without 
perforating  the  membrane.  When  the  membrane 
gives  way  owing  to  a  violent  concussion  transmitted 
through  the  air,  it  often  gives  way  opposite  the  notch, 
its  attachments  here  being  obviously  less  secure  than 
elsewhere.  The  membrane  possesses  but  little  elasticity, 
as  shown  by  the  very  slight  gaping  of  the  part  after  it 
has  been  wounded.  It  is  for  this  reason,  among  others, 
that  perforations  made  in  the  membrane  by  the  surgeon 
heal  so  very  rapidly.  The  membrane  has  been  ruptured 
during  fits  of  sneezing,  coughing,  vomiting,  etc.  The 
same  lesion  has  followed  a  box  on  the  ear,  and  even 
simple  concussions  such  as  that  produced  by  a  loud 
report. 

The  umbo,  or  deepest  point  of  the  depression  in  the 
diaphragm,  is  just  below  the  centre  of  the  entire  mem- 
brane, and  corresponds  to  the  attachment  of  the  end 
of  the  handle  of  the  malleus.  The  rest  of  the  handle 
can  be  seen  through  the  membrane  during  life.  The 
head  of  the  malleus  is  in  no  connection  with  the  mem- 
brane, being  situated  in  the  attic  of  the  tympanum 
above  the  level  of  the  membrane.  The  segment  of  the 
membrane  above  the  umbo  is  very  freely  supplied  by 
vessels  and  nerves  ;   it  corresponds  to  the  handle  of  the 


chap,  v.]  The  Ear.  75 

malleus,  and  to  the  chain  of  ossicles,  and  is  opposite  to 
the  promontory  and  the  two  fenestra?.  The  chorda 
tympani  nerve  also  runs  across  this  supraumbilical 
portion.  The  segment  below  the  umbo,  on  the  other 
hand,  corresponds  to  no  very  important  parts,  and  is  less 
vascular  and  less  sensitive.  Paracentesis  of  the  tym- 
panum through  the  membrana  tympani  should  therefore 
always  be  performed  in  the  subumbilical  segment. 
If  performed  above  the  umbo  the  knife  may  strike 
the  incus  and  loosen  that  bone  from  its  frail  attach- 
ments, or  the  chorda  tympani  be  cut,  which  would  give 
rise  to  a  paralytic  secretion  of  saliva.  The  malleus  and 
stapes  are  too  firmly  attached  to  be  readily  separated. 

The  membrane  is  supplied  by  the  stylo-mastoid 
artery,  and  the  tympanic  branch  of  the  internal  max- 
illary, and  obtains  its  nerve  supply  from  the  auriculo- 
temporal. 

The  tympanum.— The  width  of  the  tympanic 
cavity,  as  measured  from  its  inner  to  its  outer  wall, 
varies  from  r^th  to  \Xh  of  an  inch.  The  narrowest 
part  is  that  between  the  umbilicus  of  the  membrana 
and  the  promontory.  A  fine  rod  thrust  through  the 
centre  of  the  membrana  tympani  would  hit  the  pro- 
montory on  the  inner  wall  of  the  cavity.  Above  the 
promontory  is  the  fenestra  ovalis,  and  below  and  behind 
it  the  fenestra  rotunda.  Skirting  the  upper  and 
posterior  margin  of  the  inner  wall  of  the  tympanum 
is  the  aqueduct  of  Fallopius,  containing  the  facial  nerve. 
The  wall  of  the  aqueduct  is  so  thin  that  inflammatory 
mischief  can  readily  extend  from  the  middle  ear  to 
the  facial  nerve.  The  upper  wall  is  very  thin,  and  but 
little  bone  separates  it  from  the  cranial  cavity.  The 
suture  between  the  squamous  and  petrous  bones  is  found 
in  this  wall,  and  by  means  of  the  sutural  membrane 
that  separates  the  bones  in  the  young,  inflammatory 
changes  may  readily  spread  from  the  tympanum  to 
the  meninges.  The  petro-squ anions  suture  unites  at 
the  end  of  the  first  year  and  usually  contains  the  petro- 
squamous vein,  a  remnant  of  the  primitive  jugular. 
The   floor  is   very   narrow.     Its  lowest   part  is   below 


76 


Surgical  Applied  Anatomy.       [Chap.  v. 


the  level  of  both  the  membrana  tympani  and  the  orifice 
of  the  Eustachian  tube,  and  hence  pus  may  readily 
collect  in  this  locality.  It  is  separated  by  a  thin  piece 
of  bone  from  the  internal  jugular  vein  behind,  and 
from  the  internal  carotid  artery  in  front.  Fatal  hsepaor- 
rhage  from  the  latter  vessel  has  occurred  in  connection 
with  destructive  changes  in  this  part  of  the  ear.     The 


/'     HELIX.    \ 


SQUAM.    •' 


Fig.  15.— Showing  the  Position  and  Relationships  of  the  Antrum  of  the 
Mastoid  (see  also  Fig.  3). 

a,  Antrum.  The  suprameatal  triangle  is  indicated  in  front  of  the  letter.  The 
shaded  space  in  front  of  the  triangle  and  above  the  meatus  is  the  attic  of 
the  tympanum  ;  x  x  on  the  continuation  of  the  upper  border  of  the  zygoma 
backwards  indicating  the  position  of  the  tegmen  tympani ;  e,  placed  on  the 
floor  of  the  external  auditory  meatus.  The  tympanum  is  seen  in  the  depth 
of  the  meatus;  vn.  showing  the  position  of  the  facial  nerve ;  l.s.,  lateral 
sinus;  m.f.,  mastoid  foramen ;  zy.,  root  of  zygoma;  co>\,  condyle  of  jaw. 
The  outline  of  the  auricle  is  indicated  by  a  single  dotted  line;  that  of  the 
facial  nerve  by  a  double  dotted  line. 


posterior  wall  in  its  upper  part  presents  the  opening 
of  the  antrum  of  the  mastoid. 

The  antrum  of  the  mastoid  (Fig.  15)  lies  above 
and  behind  the  external  auditory  meatus  and  opens  into 
the  attic  of  the  tympanum.  Implication  of  this  space 
and  of  the  mastoidal  cells,  which  open  into  it  and 
surround  it,  forms  one  of  the  most  serious  complications 
of  middle  ear  disease.  It  is  large  enough  to  contain 
a  small  bean,  and  is  present  at  birth,  being  developed 
with  the  cavity  of  the  tympanum.  It  is  closely  sur- 
rounded by  important  structures.     Its  roof,  formed  by 


Chap,  v.]  The  Ear.  77 

the  tegrnen  tympani,  a  plate  of  bone  only  2  mm.  thick, 
separates  it  from  the  third  temporal  convolution.  Small 
veins  perforate  the  roof  to  join  the  petro-squanious 
vein,  in  the  remnant  of  the  suture  of  the  same  name. 
In  the  infant  the  communication  is  even  more  free, 
for  this  suture  does  not  close  until  the  end  of  the  first 
year.  The  facial  nerve  passes  downwards  on  its  inner 
wall,  where  the  antrum  opens  into  the  attic,  and  behind 
the  facial  nerve,  also  on  the  inner  wall,  is  the  external 
semi-circular  canal.  Facial  paralysis  or  giddiness  may 
follow  operations  on  the  antrum  if  the  inner  wall  is 
injured.  The  antrum  is  separated  behind  from  the 
lateral  sinus  and  cerebellum  by  a  plate  of  bone  which. 
varies  in  thickness  from  3  mm.  to  6  mm.  The  temporo- 
sphenoidal  lobe,  the  lateral  sinus,  and  the  cerebellum 
are  the  common  seats  of  secondary  infection  in  cases 
of  middle  ear  disease.  At  the  mouth  of  the  antrum 
and  in  the  attic  of  the  tympanum  are  situated  the  incus, 
the  head  of  the  malleus,  and  their  ligaments,  structures 
which  may  be  diseased  and  require  removal. 

At  birth  the  outer  wall  of  the  antrum  is 
formed  by  the  post-meatal  process  of  the  squamosal, 
a  plate  of  bone  2  mm.  thick.  Every  year,  until 
about  the  twentieth,  this  process  of  bone  increases 
about  1  mm.  in  thickness,  and  hence  in  the  adult 
the  mastoidal  antrum  lies  at  a  depth  of  20  mm.  from 
the  surface,  but  it  must  be  remembered  that  the  depth 
varies  considerably.  In  the  child  it  is  comparatively 
superficial,  and  pus  may  easily  escape  or  be  evacuated. 
The  suture  between  the  post-meatal  part  of  the  squamosal 
and  the  petro-mastoid  disappears  in  the  second  year 
of  life  and  so  shuts  off  a  possible  route  that  pus  may 
take  to  reach  the  surface.  A  shallow  triangle  {see 
Fig.  15)  above  and  behind  the  meatus,  formed  by  the 
post-meatal  process  of  the  squamosal,  lies  directly  over 
the  antrum  and  serves  as  a  guide  to  it.  It  may  also 
be  reached  by  following  the  junction  of  the  posterior 
wall  and  roof  of  the  external  auditory  meatus.  The 
drill  is  entered  5  mm.  behind  the  meatus  and  on  a  level 
with  its  upper  margin.     Its  roof  lies  5  mm.  above  the 


78  Surgical  Applied  Anatomy.       [Chap.  v. 

level  of  the  meatus.  The  posterior  auricular  artery 
passes  upwards  behind  the  meatus,  beneath  the  concha 
of  the  auricle,  and  lies  within  the  field  of  any  operation 
on  the  middle  ear. 

The  mastoid  cells  develop  with  the  growth  of  the 
mastoid  process.  The  mastoid  process  appears  in  the 
third  year,  but  the  cells  are  not  formed  until  puberty. 
Three  varieties  of  the  mastoid  process  are  recognised,  each 
of  which  is  about  equally  common  :  (1)  those  in  which 
the  cells  are  large  and  communicate  with  each  other 
and  with  the  antrum,  (2)  those  in  which  the  central 
cells  are  large  and  communicate  with  the  antrum, 
while  the  peripheral  are  small  and  closed,  (3)  those  in 
which  all  the  spaces  are  small  and  closed.  The  cells 
surround  the  antrum,  and  may  pass  backwards  to  the 
masto-occipital  suture,  forwards  to  the  suprameatal 
region,  upwards  to  the  masto-parietal  suture,  and  down- 
wards to  the  apex  of  the  mastoid.  Inflammatory 
conditions  may  lead  to  a  thickening  of  the  walls  of  the 
mastoidal  cells,  and  the  bone  may  become  so  dense  as 
almost  to  resist  the  chisel.  Veins  drain  into  the  peri- 
osteum of  the  mastoid  from  the  more  superficial  cells, 
and  by  these,  inflammation  may  reach  the  surface 
and  give  rise  to  oedema  and  swelling  behind  the  ear. 

In  cases  where  the  outer  surface  of  the  mastoid 
has  been  spontaneously  perforated,  a  tumour  has 
appeared  on  the  skull  that  contained  air,  and  that 
could  be  increased  in  size  by  forcing  air  into  the  ear 
through  the  Eustachian  tube.  Such  tumours  are 
known  as  pneumatoceles,  and  the  process  that  leads 
originally  to  the  perforation  of  the  bone  is  of  obscure 
nature.  In  some  cases  it  seems  to  have  been  simply 
atrophic,  and  in  other  instances  to  have  been  due  to 
"  caries  sicca." 

On  the  anterior  wall  of  the  tympanum  is  the  opening 
of  the  Eustachian  tube.  This  tube  is  If  inches 
long,  and  by  opening  into  the  pharynx  serves  to  keep 
a  proper  supply  of  air  in  the  tympanum,  and  so  equalise 
the  pressure  upon  the  two  sides  of  the  membrane.  The 
floor  of  the  tympanum  is  below  the  level  of  the  outer 


Chap,  v.]  The  Ear.  79 

opening  of  the  Eustachian  tube.  The  line  of  direction  of 
the  tube  lies  almost  exactly  midway  between  the  trans- 
verse and  antero-posterior  axes  of  the  base  of  the  skull. 
In  the  adult  it  inclines  downwards,  so  as  to  form  an  angle 
of  40°  with  the  horizon.  In  the  child  this  angle  is  only 
10°  (Symington).  In  adults  fths  of  the  tube  is  carti- 
laginous and  Jth  bony  (Symington).  On  the  outer 
side  of  the  tube  lie  the  tensor  palati,  the  third  division 
of  the  fifth  nerve,  and  the  middle  meningeal  artery. 
On  the  inner  side  are  the  retro-pharyngeal  tissue  and 
(quite  posteriorly)  the  internal  carotid  artery.  The 
pharyngeal  orifice  of  the  tube  is  usually  shut.  During 
swallowing,  however,  it  is  opened,  by  the  action  mainly 
of  the  tensor  palati  muscle.  If  the  nose  and  mouth 
be  closed  and  the  cheeks  blown  out,  a  sense  of  pressure 
is  produced  in  both  ears.  The  hearing,  at  the  same 
time,  is  dulled,  and  the  change  is  due  to  the  bulging  out 
of  the  membrana  tympani  by  the  air  thus  forced 
into  the  tympanum.  This  method  of  inflating  the 
middle  ear  is  known  as  Valsalva's  method. 

In  "  Politzer's  method "  of  passing  air  into  the 
Eustachian  tube,  the  patient's  mouth  is  closed,  while 
into  one  nostril  the  nozzle  of  a  caoutchouc  bag  filled  with 
air  is  introduced,  and  the  nostrils  are  then  held  firmly 
closed.  The  patient  is  asked  to  swallow  a  mouthful 
of  water,  while  at  the  same  moment  the  bag  is  forcibly 
emptied,  and  the  air,  having  no  other  means  for  escape, 
is  thus  driven  into  the  open  Eustachian  tube.  The 
surgeon  listens  for  the  little  noise  caused  by  the  entrance 
of  the  air  by  means  of  a  tube  that  passes  between  the 
patient's  meatus  and  his  own.  Prolonged  closure  of 
the  Eustachian  tube  leads  to  deafness,  and  thus  impair- 
ment of  hearing  may  follow  upon  great  thickening 
of  the  mucous  membrane  of  the  tube  due  to  the  extension 
of  inflammatory  mischief  from  the  pharynx.  In  the 
deafness  associated  with  enlarged  tonsils  and  post-nasal 
growths,  the  hypertrophic  change  extends  to  the  mucous 
lining  of  the  tube,  and  in  the  cases  of  many  pharyngeal 
growths  and  nasal  polypi,  the  orifice  of  the  tube  is 
mechanically   obstructed.       The   near   relation   of   the 


8o  Surgical  Applied  Anatomy.       [Chap.  v. 

pharyngeal  end  of  the  tube  to  the  posterior  nares  serves 
to  explain  a.  case  where  suppuration  in  the  mastoid 
cells  followed  upon  plugging  of  the  nares  for  epistaxis. 
A  probe  passed  up  the  Eustachian  tube  from  the  pharynx 
would  hit  the  joint  between  the  incus  and  the  stapes, 
and  would  enter  the  mastoid  cells  (Tillaux). 

The  upper  edge  of  the  pharyngeal  orifice  of  the 
tube  is  about  half  an  inch  below  the  basilar  process, 
half  an  inch  in  front  of  the  posterior  wall  of  the  pharynx, 
half  an  inch  behind  the  posterior  end  of  the  inferior 
turbinated  bone,  and  half  an  inch  above  the  soft  palate 
(Tillaux).  In  the  foetus  the  orifice  is  below  the  hard 
palate  ;  at  birth  on  the  same  level.  The  form  of  the 
opening  is  that  of  a  triangle.  The  opening  of  the  tube 
is  effected  by  the  tensor  palati,  levator  palati,  and  sal- 
pingo-pharyngeus. 

Just  behind  the  elevation  formed  at  the  orifice  of 
the  Eustachian  tube  there  is  a  depression  in  the  wall 
of  the  pharynx,  known  as  the  lateral  recess  or  fossa  of 
Rosenmuller  (Fig.  16).  It  may  be  mistaken  for  the 
orifice  of  the  tube,  and  may  readily  engage  the  point 
of  a  Eustachian  catheter.  In  cases  in  which  the 
pharyngeal  tonsil  (Luscha's  tonsil)  is  enlarged,  this 
fossa  on  either  side  may  be  greatly  deepened  and  made 
to  form  a  narrow  diverticulum.  (See  page  131.)  To 
pass  the  Eustachian  catheter,  the  instrument  is  carried 
along  the  floor  of  the  nares  with  its  concavity  downwards, 
"  until  its  point  can  be  felt  to  drop  over  the  posterior  edge 
of  the  hard  palate  into  the  pharynx.  The  instrument 
should  now  be  withdrawn  until  its  point  can  be  felt  to 
rise  again  on  the  posterior  edge  of  the  hard  palate  ; 
having  arrived  at  this  point,  the  catheter  should  be 
pushed  onwards  about  one  inch,  and  during  its  passage 
its  point  should  be  rotated  outwards  through  a  quarter 
of  a  circle."*  This  manoeuvre  should  engage  it  on 
the  orifice  of  the  tube. 

Blood  supply.— The  tympanum  is  supplied  by 
the  following  arteries  :    the  tympanic  of  the  internal 

*  Smith  and  Walsham's  "  Operative  Surgery,"  p.  12.     2nd  Ed. 
1876. 


Chap. vi.]  The  Nose.  Si 

maxillary  and  internal  carotid,  the  petrosal  of  the  middle 
meningeal,  and  the  stylomastoid  of  the  posterior  auricu- 
lar. The  fact  that  some  of  the  tympanic  veins  end  in 
the  superior  petrosal  and  lateral  sinuses  gives  another 
explanation  of  the  frequent  occurrence  of  thromboses 
of  those  channels  in  inflammatory  affections  of  the 
middle  ear.  The  petrosquamous  vein,  which  crosses 
the  roof  of  the  middle  ear,  also  receives  branches  from 
the  antrum  and  attic  and  joins  the  lateral  sinus  behind 
and  the  meningeal  veins  in  front  (Cheatle). 

The  connection  between  deafness  and  tinnitus  aurium 
and  affections  of  the  stomach  has  to  be  sought  for  in  the 
central  connections  of  the  eighth  and  tenth  nerves. 
The  blood  supply  of  the  labyrinth  is  derived  entirely 
from  the  vertebral  artery  (Woakes). 

The  chorda  tympani  nerve,  from  its  exposed 
position  in  the  tympanum,  is  very  likely  to  be  damaged 
in  suppurative  disease  of  the  middle  ear  ;  and  Urban- 
tschitsch  and  Schulte  have  shown  that  such  disease  in 
this  part  may  be  associated  with  anomalies  of  taste. 

The  osseous  labyrinf  li  is  formed  independently 
of  the  other  bony  parts  of  the  ear.  Portions  of  this 
labyrinth  have  necrosed  and  have  been  expelled  in 
recognisable  fragments.  In  a  case  recorded  by  Dr. 
Barr  the  whole  of  the  osseous  labyrinth  (the  cochlea, 
vestibule,  and  semicircular  canals)  was  removed  entire 
as  a  necrosed  fragment  from  the  auditorv  meatus. 


CHAPTER    VI. 

THE    NOSE   AND    NASAL    CAVITIES. 

1.  The  nose.— The  skin  over  the  root,  and  the 
greater  part  of  the  dorsum,  of  the  nose,  is  thin  and  lax. 
Over  the  ake,  however,  it  is  thick,  very  adherent  to 
the  deeper  parts,  and  plentifully  supplied  with  sebaceous 
and  sweet  glands.  Inflammation  of  the  integuments 
over  the  cartilaginous  portion  of  the  nose  is  apt  to  be 
very  painful,  and  to  be  associated  with  much  vascular 


82  Surgical  Applied  Anatomy.      [Chap.  vi. 

engorgement.  The  pain  depends  upon  the  tenseness 
of  the  part,  which  prevents  it  from  swelling  without 
producing  much  pressure  upon  the  nerves,  while  the 
engorgement  depends  upon  the  free  blood  supply  of  the 
region,  and  the  fact  that  the  edge  of  the  nostril  being  a 
free  border,  the  circulation  there  is  terminal,  and  apt 
therefore  to  favour  congestion. 

The  great  number  of  sebaceous  glands  about  the 
lower  part  of  the  nose  renders  it  a  favourite  spot  for 
acne.  It  is  here  that  the  form  of  acne  termed  acne 
hypertrophica  is  met  with,  a  condition  that  produces 
the  appearance  known  as  "  grog  blossoms."  The  nose, 
too,  is  frequently  attacked  by  lupus,  and  it  is  indeed 
over  the  dorsum  of  the  nose  that  lupus  erythematosus 
is  most  commonly  met  with.  Rodent  ulcer  also  is  apt 
to  appear  in  this  region,  especially  in  the  fold  between 
the  ala  of  the  nose  and  the  cheek. 

The  integument  of  the  nose  is  very  well  supplied 
with  blood,  and  for  this  reason  the  part  is  well  suited 
for  the  many  plastic  operations  that  are  performed 
upon  it.  Wounds  in  this  region  heal  kindly,  and  even 
the  extensive  wound  made  along  the  line  between  the 
nose  and  the  cheek  in  removal  of  the  upper  jaw  leaves 
very  little  deformity.  In  many  reported  cases  portions 
of  the  nose  have  been  entirely  severed,  and  have  united 
to  the  face  on  being  immediately  re-applied.  In  spite 
of  its  full  blood  supply,  the  nose,  for  reasons  already 
given  when  speaking  of  the  pinna  (page  72),  is  prone 
to  gangrene  from  exposure  to  severe  cold.  A  specimen 
in  the  museum  of  the  Royal  College  of  Surgeons  illus- 
trates a  remarkable  form  of  gangrene  of  the  nose.  The 
specimen  is  the  larynx  of  a  man  who  cut  his  throat 
and  lost  a  great  quantity  of  blood.  Before  he  died  his 
nose  sloughed. 

The  skin  over  the  root  of  the  nose  is  supplied  by 
the  nasal  branch  of  the  first  division  of  the  fifth  ;  as 
is  also  the  skin  over  the  alse  and  in  the  region  of  the 
nostril.  The  middle  or  greater  part  of  the  side  of  the 
nose  is  supplied  by  the  second  division  of  the  fifth,  and 
is  the  seat  of  pain  in  neuralgia  of  that  trunk.       The 


Chap.  vi.  j  The  Nose.  £3 

fact  that  the  nasal  nerve  is  a  branch  of  the  ophthalmic 
trunk,  and  has  intimate  connections  with  the  eye, 
serves  to  explain  the  lachrymation  that  often  follows 
painful  affectio'hs  about  the  nostril,  as,  for  example, 
when  the  edge  of  the  nostril  is  pinched  (page  46). 

The  cartilaginous  part  of  the  nose  is  often 
destroyed  by  lupus,  by  syphilitic  ulceration,  and  other 
destructive  affections.  The  parts  so  lost  have  been 
replaced  by  the  various  methods  included  under  the 
head  of  rhinoplasty.  It  is  well  to  bear  in  mind  the 
limits  of  the  cartilaginous  segment  of  the  nose,  and 
to  remember  that  in  introducing  a  dilating  speculum 
the  instrument  should  not  be  passed  beyond  those 
limits.  In  the  subjects  of  inherited  syphilis  the  bridge 
of  the  nose  is  often  found  to  be  greatly  depressed.  This 
depends  upon  no  actual  loss  of  parts,  but  rather  upon 
imperfect  development  from  local  mal-nutrition,  that 
mal-nutrition  following  upon  a  severe  catarrh  of  the 
mucous  membrane.  The  deformity  only  occurs,  there- 
fore, in  those  who  have  had  "  snuffles  "  in  infancy. 

The  na§al  bones  are  often  broken  by  direct 
violence.  The  fracture  is  most  common  through  the 
lower  third  of  the  bones,  where  they  are  thinnest  and 
least  supported.  It  is  rarest  in  the  upper  third,  where 
the  bones  are  thick  and  firmly  held,  and  where,  indeed, 
considerable  force  is  required  to  produce  a  fracture. 
Since  no  muscles  act  upon  the  ossa  nasi,  any  displace- 
ment that  occurs  is  due  solely  to  the  direction  of  the 
force.  Union  takes  place  after  these  fractures  with 
greater  rapidity  than  perhaps  obtains  after  fracture 
of  any  other  bone  in  the  body.  In  one  case  noted  by 
Hamilton,  "  the  fragments  were  quite  firmly  united 
on  the  seventh  day."  If  the  mucous  membrane  of  the 
nose  be  torn,  these  fractures  are  apt  to  be  associated 
with  emphysema  of  the  subcutaneous  tissue,  which  is 
greatly  increased  on  blowing  the  nose.  The  air  in  such 
cases  is  derived,  of  course,  from  the  nasal  fossge.  In 
fractures  of  the  upper  third  of  the  ossa  nasi  the  cribri- 
form plate  may  be  broken,  but  it  is  questionable  whether 
this  complication  can  occur  when  the  fracture  is  limited 


84.  Surgical  Applied  Anatomy.      [Chap.vi. 

to  the  lower  third  of  the  bones.  The  root  of  the  nose  is 
a  favourite  place  for  meningoceles  and  encephaloceles, 
the  protrusion  escaping  through  the  suture  between  the 
nasal  and  frontal  bones.  Such  protrusions,  when  occur- 
ring in  this  place,  are  often  covered  by  a  thin  and  vascu- 
lar integument,  and  have  been  mistaken  for  nsevoid 
growths. 

2.  The  nasal  cavities. — The  anterior  nares 
have  somewhat  the  shape  of  the  heart  on  a  playing 
card,  and  the  aperture  as  a  whole  measures  about  \\ 
inches  vertically,  and  a  little  less  than  \\  inches  trans- 
versely, at  its  widest  part.  The  plane  of  the  nostril 
is  a  little  below  that  of  the  floor  of  the  nares.  To  ex- 
amine the  nasal  cavities,  therefore,  the  head  should  be 
thrown  back,  and  the  nose  drawn  upwards.  The 
anterior  nares  can  be  well  explored  by  the  finger  intro- 
duced into  the  nostril,  and  the  nasal  apertures  are  just 
so  wide  on  each  side  of  the  septum  as  to  allow  the  finger 
to  be  passed  far  enough  back  to  reach  another  finger 
introduced  into  the  posterior  nares  through  the  mouth. 
An  effectual  way  of  removing  soft  polypi  in  the  adult 
is  by  tearing  them  away  by  the  two  fingers  so  introduced. 
The  operation  is  a  little  rough.  By  the  most  gentle 
introduction  of  the  finger  into  the  nostril  it  is  often 
possible  to  feel  the  end  of  the  inferior  turbinated  bone. 
The  anterior  nares,  and  front  of  the  nasal  cavities,  can 
be  well  explored  by  Rouge's  operation.  In  this  pro- 
cedure the  upper  lip  is  everted,  and  a  transverse  cut 
made  through  the  mucous  membrane  into  the  soft  parts 
that  connect  the  upper  lip  with  the  upper  jaw.  The 
incision  extends  between  the  second  bicuspid  teeth  of 
either  side.  The  soft  parts  connecting  the  upper  lip 
and  nose  to  the  bone  are  divided  without  damaging  the 
skin,  and  the  flap  is  dissected  up  until  the  nares  are 
sufficiently  exposed. 

The  posterior  nares.— If  a  little  mirror, 
somewhat  similar  to  that  used  in  laryngoscopy,  be 
cautiously  introduced  behind  the  soft  palate  through 
the  month,  and  illumined  from  the  mouth,  the  following 
parts  may,  under  favourable  circumstances,  be  seen  : 


Chap,  vi.]  The  Nasal   Cavities.  85 

the  posterior  nares,  the  septum,  the  middle  turbinated 
bone,  part  of  the  superior  and  inferior  turbinated  bones, 
and  part  of  the  inferior  meatus.  The  middle  meatus 
is  well  seen,  and  also  the  Eustachian  tube,  and  the  mucous 
membrane  of  the  upper  part  of  the  pharynx. 

This  mode  of  examination  is  very  difficult  to  carry 
out,  and  is  known  as  posterior  rhinoscopy.  The  parts 
just  named  can  all  be  felt  by  the  finger  introduced 
behind  the  soft  palate  through  the  mouth.  The  posterior 
nares  are  often  plugged  to  arrest  severe  bleeding  from 
the  nose,  and  in  order  to  cut  a  proper  sized  plug  it  is 
desirable  to  bear  in  mind  the  dimensions  of  the  apertures. 
Each  aperture  is  of  regular  shape,  and  measures  about 
\  an  inch  transversely  by  \\  inches  in  the  vertical 
direction  in  a  well-developed  adult  skull. 

As  regards  the  nasal  cavities  generally,  it  is  well  to 
note  that  the  floor  is  wider  at  the  centre  than  at  either 
end,  that  the  vertical  diameter  is  greater  than  the 
transverse,  and  is  greatest  also  about  the  centre  of  the 
fossae.  Forceps  introduced  into  the  nose,  therefore, 
are  most  conveniently  opened  if  opened  vertically. 
The  width  of  the  fossae  increases  somewhat  from  above 
downwards,  thus  the  superior  turbinated  bone  is  only 
2  mm.  from  the  septum,  while  a  space  of  from  4  to  5  mm. 
intervenes  between  the  inferior  turbinated  bone  and 
the  septum.  The  nasal  cavity  is  so  very  narrow  above 
the  middle  turbinated  bone  that  that  bone  really  forms 
the  surgical  roof  of  the  nasal  fossae. 

From  a  reference  to  the  relations  of  the  nasal  fossae 
(Fig.  16)  it  will  be  understood  that  inflammation  of  the 
lining  membrane  (coryza)  may  extend  to  the  pharynx 
via  the  posterior  nares  ;  may  extend  up  the  Eustachian 
tube  and  cause  some  deafness  ;  may  reach  the  lachrymal 
sac  and  conjunctiva  through  the  nasal  duct ;  and  may 
extend  to  the  frontal  sinuses  and  the  antrum,  producing 
frontal  headache  and  cheek-ache.  These  relationships 
are  often  demonstrated  in  a  severe  "  cold  in  the  head." 
From  the  nearness  of  the  nasal  fossae  to  the  cranial 
cavity  it  happens  that  meningitis  has  followed  upon 
purulent   inflammations   of   the   nose.     Foreign   bodies 


86  Surgical  Applied  Anatomy.      [Chap.  vi. 

of  various  kinds  are  often  lodged  in  the  nose,  and  may 
remain  there  for  some  years.  Thus  Tillaux  reports 
the  case  of  an  old  woman,  aged  64,  from  whose  nose 
he  removed  a  cherry  stone  that  had  been  there  for 
twenty  years. 

In  washing  out  the  nasal  cavities  with  the  "nasal 
douche "  the  fluid  is  introduced  by  means  of  a 
syphon.  The  nozzle  of  the  syphon  tube  is  introduced 
into  one  nostril,  the  mouth  is  kept  open,  and  the  fluid 
runs  through  that  nostril,  passes  over  the  soft  palate, 
and  escapes  from  the  other  nostril.  The  latter  cavity 
is  therefore  washed  out.,  from  behind  forwards.  The 
course  of  the  fluid  depends  upon  the  fact  that  when 
the  mouth  is  kept  open  there  is  such  a  disposition  to 
breathe  through  it  alone  that  the  soft  palate  is  drawn 
up  and  the  nares  cut  off  from  the  pharynx. 

The  roof  of  each  nasal  fossa  is  very  narrow,  being 
only  about  \  of  an  inch  in  width.  It  is  mainly  formed 
by  the  thin  cribriform  plate,  but  its  width  is  such  that 
the  danger  of  the  roof  being  penetrated  by  so  large 
a  substance  as  a  pair  of  polyp  forceps  has  been  greatly 
exaggerated.  The  cranial  cavity  has,  however,  been 
opened  up  through  the  roof  of  the  nose  by  penetrating 
bodies  introduced  both  by  accident  and  with  homicidal 
intent.  Meningitis  has  followed  inflammation  of  the 
nasal  fossae,  the  inflammation  extending  through  the 
cribriform  plate.  Through  the  perineural  and  peri- 
vascular sheaths  the  lymphatic  system  of  the  nose  is 
in  continuity  with  that  of  the  meninges,  and  by  these 
channels  infections  may  spread  from  the  roof  of  the 
nose  to  the  membranes  of  the  brain.  Fracture  of  this 
part  also  has  been  associated  with  very  copious  escape 
of  cerebro-spinal  fluid  through  the  nostrils.  A 
meningocele  may  protrude  through  the  nasal  roof.  In 
a  case  reported  by  Lichtenberg  the  mass  hung  from  the 
mouth,  having  passed  through  a  congenital  fissure  in 
the  palate.  It  was  mistaken  for  a  polyp,  was  ligatured, 
and  death  resulted  from  intracranial  inflammation. 

The  septum'  is  seldom    quite  straight  in  adults  ; 
the  deviation  being  more  often  towards  the  left.     It  is, 


Chap,  vi.]  The  Nasal   Cavities.  87 

however,  straight  in  children,  and  remains  so  up  to 
the  seventh  year.  In  adults  the  septum  deviates  in 
76  per  cent,  of  all  persons.  The  deviation  may 
follow  an  injury.  It  has  been  pointed  out  that 
a  deviation  of  the  septum  may  seriously  interfere  with 
the  singing  voice.  The  nose  also  is  seldom  quite  straight, 
and  French  authors  ascribe  this  to  some  deviation  of 
the  septum,  often  dependent  upon  the  practice  of  always 
blowing  the  nose  with  the  same  hand.  If  the 
deviation  of  the  septum  be  considerable,  it  may  more  or 
less  block  one  nostril,  and,  until  the  opposite  nostril  is 
examined,  be  mistaken  for  a  septal  tumour  encroaching 
upon  the  cavity.  The  flattened  nose  in  acquired  syphilis 
is  usually  due  to  destruction  of  the  septum  and  more 
or  less  implication  of  the  adjacent  bones.  Workmen 
exposed  to  the  vapour  of  bichromate  of  potash  are  liable 
to  a  peculiar  perforation  of  the  septum  known  as 
"  bichromate  disease." 

Outer  wall  (Fig.  16). — The  inferior  turbinated  bone 
may  interfere  with  the  introduction  of  a  Eustachian 
catheter  if  the  curve  of  the  instrument  be  too  great. 
The  anterior  end  of  the  bone  is  about  f  of  an  inch  behind 
the  orifice  of  the  nostril.  The  opening  of  the  nasal  duct 
is  about  1  inch  behind  the  orifice  of  the  nostril,  and 
about  f  of  an  inch  above  the  nasal  floor.  This  opening 
is  usually  slit-like  and  narrow.  The  nasal  duct  pierces 
the  nasal  mucous  membrane  in  the  same  oblique  and- 
valvular  manner  as  the  ureter  enters  the  bladder.  The 
height  of  the  inferior  meatus  is  about  f  of  an  inch.  The 
superior  meatus  is  a  very  short  and  narrow  fissure,  and 
into  its  upper  and  fore  part  open  the  posterior  ethmoidal 
cells.  The  middle  meatus  opens  widely  in  front  upon 
a  part  of  the  outer  wall  called  the  atrium,  and  unless 
care  be  taken  to  keep  the  point  of  any  instrument  well 
towards  the  floor  of  the  fossa,  it  is  easier  to  pass  the 
instrument  into  the  middle  than  into  the  inferior  meatus. 
Upon  the  wall  of  the  middle  meatus  is  a  deep  gutter  (the 
hiatus  semilunaris),  which  runs  from  above  downwards 
and  backwards  (Fig.  16).  Into  this  groove  open  the 
infundibulum  (the  aperture  of  the  frontal  sinus),  the 


88  Surgical  Applied  Anatomy.      [Chap.  vi. 

anterior  ethmoid  cells,  and,  near  its  posterior  end,  the 
antrum.  The  aperture  of  the  frontal  sinus  appears  as 
a  small  round  hole  at  the  upper  and  anterior  end  of 
the  groove.  The  ethmoid  cells  open  a  little  way  lower 
down  on  the  groove,  while  the  antrum  has  its  orifice  at 
or  near  the  hinder  part  of  the  hiatus.  This  orifice  is 
slit-like,  situated  about  the  centre  of  the  middle  meatus, 
and  is  quite  1  inch  above  the  floor  of  the  nasal  fossae 
(Fig.  16).  The  orifice  is  nearer  to  the  roof  than  the 
floor  of  the  antrum,  and  thus  no  facility  is  offered  for 
the  escape  of  accumulated  fluids. 

The  middle  turbinated  bone  is  high  up.  Its  highest 
point  (its  anterior  extremity)  is  nearly  on  a  level  with 
the  "te  ndo  oculi. 

Rhinolithes  (stone-like  masses  of  calcareous  matter, 
formed,  as  a  rule,  around  foreign  substances)  are  most 
often  found  in  the  inferior  meatus. 

The  width  of  the  nasal  floor  is  about  ^  an  inch, 
or  a  little  over.  Its  smooth  surface  greatly  favours 
the  passage  of  instruments.  It  presents  a  gentle  slope 
from  before  backwards.  At  its  anterior  part  is  a 
depression  of  mucous  membrane  over  the  incisor 
foramen.  This  foramen  is  a  vestige  of  the  great  com- 
munication that  once  existed  between  the  cavities  of 
the  nose  and  mouth. 

The  mucous  membrane  lining  the  nasal  cavi- 
ties varies  in  parts.  It  is  very  thick  and  vascular  over 
the  turbinate  bones  and  over  the  lower  two-thirds  of 
the  septum,  while  over  the  nasal  floor  and  in  the  intervals 
between  the  turbinate  bones  it  is  very  much  thinner. 
The  mucous  membrane  lining  the  various  sinuses  and 
the  antrum  is  conspicuously  thin  and  pale.  The  mem- 
brane is  provided  with  many  glands,  which  are  most 
conspicuous  over  the  lower  and  hinder  parts  of  the  outer 
wall  and  over  the  posterior  and  inferior  parts  of  the 
septum.  These  glands  may  be  the  subject  of  consider- 
able hypertrophy.  They  are  capable  of  providing  also 
a  very  copious  watery  secretion,  which  has  in  some 
cases  of  chronic  coryza  following  injury  been  so  free 
as  to  be  mistaken  for  an  escape  of  cerebro-spinal  fluid. 


Chap.  VI.] 


The  Nasal  Cavities. 


89' 


There  is  also  much  adenoid,  or  lymphoid,  tissue  in  the 
nasal  mucous  membrane,  which  is  the  primary  seat  of 
the  chief  scrofulous  affections  that  invade  this  part. 
So  thick  and  lax  is  the  normal  mucous  membrane  over 


Fig.  16.— Outer  Wall  of  the  Nose,  showing  the  Openings  of  the  Sinuses. 
The  middle  (m.t.)  and  inferior  (i.t.)  turbinate  processes  have  been  cut 
off  at  their  attachments,  but  their  outlines  are  indicated. 

f.s.,  Frontal  sinus;  IK.,  infundibulum  opening  into  the  middle  meatus  at  the  upper 
end  of  the  hiatus  semilunaris  ;  h,  placed  on  the  bulla  ethmoidals  below  the 
opening  of  the  middle  ethmoidal  cell  (2)  and  above  ihe  hiatus  semilunaris ; 
a,  the  opening  of  the  antrum  at  the  posterior  end  of  the  hiatus ;  b,  on  the 

atrium  in  front  of  the  beak  of  the  middle  turbinate  process;  N.D.,  opening 
of  the  nasal  duct ;  (1),  posterior  ethmoidal  cell  opening  in  superior  meatus  ; 
(3)  anterior  ethmoidal  cell  opening  into  infundibulum ;  (4),  lachrymo- 
ethmoidal  cell,  also  opening  into  infundibulum  ;  p,  position  of  pituitary 
body;  s.s.,  sphenoidal  sinus;  l.  i:.,  lateral  recess  of  pharynx  ;  BUS.,  Eusta- 
chian tube. 


the  lower  borders  and  posterior  extremities  of  the  middle 
and  inferior  turbinated  bones  that  it  forms  in  these 
situations  a  kind  of  soft  cushion.  This  condition 
is  mainly  due  to  the  presence  of  a  rich  submucous  venous 
plexus,  the  vessels  of  which  run,  for  the  most  part,  in 
an  antero-posterior  direction.     Over  the  lower  turbinate 


90  Surgical  Applied  Anatomy.      [Chap.vi. 

bone  the  veins  form  a  kind  of  cavernous  tissue,  "  the 
erectile  body."  When  turgid  with  blood  it  swells  so  as 
to  obliterate  the  interval  between  the  bone  and  the 
septum.  When  the  seat  of  chronic  inflammation,  the 
mucous  membrane  over  the  inferior  bone  may  appear 
as  a  polypoid  swelling.  The  great  vascularity  of  the 
mucous  membrane  is  probably  for  the  purpose  of  raising 
the  temperature  of  the  inspired  air.  From  the  con- 
struction of  the  fossae  the  inspired  air  is  encouraged  to 
pass  along  the  middle  meatus,  the  expired  air  along  the 
lower  meatus.  From  the  comparatively  lax  attachment 
of  the  mucous  membrane  of  the  septum  to  the  parts 
beneath,  it  happens  that  haematoixiata  are  often  met 
with  beneath  the  septal  mucous  membrane  after  a  blow 
on  the  nose. 

Polypi  are  often  met  with  in  the  nose.  They 
are  of  two  kinds,  the  mucous  or  myxomatous  polyp 
that  springs  usually  from  the  mucous  membrane  over 
the  middle  or  inferior  turbinate  bones,  and  the  fibrous 
or  sarcomatous  polyp  that  usually  takes  origin  from 
the  periosteum  of  the  nasal  roof  or  from  that  of  the 
base  of  the  skull.  Polypi  of  the  latter  kind  spread  in 
every  available  direction.  They  expand  the  bridge  of 
the  nose,  close  the  .nasal  duct  and  cause  epiphora,  depress 
the  hard  palate,  and  encroach  upon  the  mouth,  invade 
the  antrum  and  expand  the  cheek,  grow  down  into 
the  pharynx,  pushing  forwards  the  velum  palati,  and 
may  penetrate  even  through  the  inner  wall  of  the  orbit. 
In  one  remarkable  case,  quoted  in  the  Lancet  for  1877, 
a  tumour,  springing  from  the  sheath  of  the  superior 
maxillary  nerve  just  after  its  exit  from  the  foramen 
rotundum,  projected  into  the  nasal  fossae.  It  was 
mistaken  for  a  polyp,  and  attempts  to  remove  it  led 
to  meningitis  and  death. 

The  blood  supply  of  the  nasal  cavity  is  extensive, 
and  is  derived  from  the  internal  maxillary,  ophthalmic, 
and  facial  arteries.  With  regard  to  the  veins,  it  may 
be  noted  that  the  ethmoidal  veins  that  come  from  the 
nose  enter  the  ophthalmic  vein,  while  in  children  a 
constant  communication  exists  between  the  nasal  veins 


Chap,  vi.]  The  Nasal  Cavities.  91 

and  the  superior  longitudinal  sinus  through  the  foramen 
caecum.  This  communication  may  also  be  maintained 
in  the  adult.  These  connections  may,  in  part,  serve 
to  explain  the  occurrence  of  intracranial  mischief  as 
a  consequence  of  certain  inflammatory  affections  of  the 
nasal  cavities.  Bleeding  from  the  nose,  or  eyistaxis, 
is  a  common,  and  often  a  serious,  circumstance.  Its 
frequency  is  to  a  great  extent  due  to  the  vascularity 
of  the  mucous  membrane,  to  its  laxity,  and  to  the  fact 
that  the  veins,  especially  those  over  the  lowest  turbinate 
bone,  form  extensive  plexuses,  and  produce  a  kind  of 
cavernous  tissue.  The  epistaxis  is  often  due,  therefore, 
to  interference  with  the  venous  circulation,  as  seen 
in  cases  of  cervical  tumour  pressing  upon  the  great  veins, 
in  the  paroxysms  of  whooping  cough,  and  the  like. 
The  beneficial  effect  of  raising  the  arms  in  epistaxis 
is  supposed  to  depend  upon  the  extra  expansion  of  the 
thorax  thus  produced,  and  the  aspiratory  effect  thus 
brought  to -bear  upon  the  cervical  veins.  The  bleeding 
may  be  copious  and  long  continued.  Thus  Spencer 
Watson  reports  a  case  where  the  epistaxis  continued 
on  and  off  for  twenty  months  without  obvious  cause. 
Martineau  mentions  an  instance  in  which  12  lb.  of 
blood  were  lost  in  sixty  hours,  and  Fraenkel  records  a 
case  where  75  lb.  of  blood  are  said  to  have  escaped  from 
first  to  last.  In  several  instances  the  haemorrhage  has 
proved  fatal.  The  seat  of  the  bleeding  is  often  not  easy 
to  detect,  even  when  the  examination  is  post  mortem. 
In  many  cases  the  bleeding  point  is  situated  on  the 
septum,  \  an  inch  above  and  behind  the  nasal  spine. 

The  nerve  supply  of  these  parts  is  derived  from 
the  olfactory  nerve,  and  from  the  first  and  second 
divisions  of  the  fifth  nerve.  The  lachrymation  that 
often  follows  the  introduction  of  irritants  into  the  front 
of  the  nares  may  be  explained  by  the  fact  that  that 
part  of  the  cavity  is  supplied  freely  by  the  nasal  nerve, 
a  branch  of  the  ophthalmic  trunk.  As  an  example 
of  transference  of  nerve  force  in  the  opposite  direction 
may  be  noted  cases  Avherc  a  strong  sunlight  falling 
upon   the  eyes  has   produced  an   attack  of  sneezing. 


92  Surgical  Applied  Anatomy.     [Chap. vi. 

Troubles  involving  the  vagal  centres,  such  as  cough 
and  bronchial  asthma,  have  followed  affections  of  the 
nasal  cavities.  The  vagus  nerve  contains  visceral  fibres 
which  originally  belonged  to  the  fifth  nerve.  The 
olfactory  nerves  are  situated  in  the  upper  third  of  the 
cavity,  and  thus  in  smelling  intently  the  individual 
sniffs  deeply  and  dilates  the  nostril.  The  inability  to 
dilate  the  nostril  in  facial  paralysis  may  explain  the 
partial  loss  of  smell  sometimes  noted  in  such  cases. 
It  is  said  (Althaus)  that  anosmosia,  or  loss  of  the  sense 
of  smell,  when  following  upon  an  injury  to  the  head, 
may  be  due  to  a  rupture  of  the  olfactory  nerve  fibres 
as  they  pass  through  the  cribriform  foramina.  The 
olfactory  roots  cross  the  edge  of  the  lesser  wings  of  the 
sphenoid,  and  in  falls  on  the  forehead  are  liable  to  injury. 
The  olfactory  centre  is  situated  in  the  hippocampal  gyrus. 
Surgery  affords  some  examples  of  the  possible  violence 
of  the  act  of  sneezing.  Thus  a  man  sneezed  vigorously 
when  his  hand  was  firmly  supported  upon  an  object, 
and  produced  a  subcoracoid  dislocation  of  his  shoulder 
{Lancet,  1878).  In  another  case  the  ninth  rib  on  the 
left  side  was  fractured  during  a  fit  of  sneezing  (Med. 
Times,  1862).  Mr.  Pitts  (Lancet,  1883)  has,  however, 
reported  the  strangest  case  of  all,  a  case  in  which 
all  the  coverings  of  a  large  femoral  hernia  were 
ruptured  during  the  act  of  sneezing,  so  that  the 
bowels  escaped. 

Some  of  the  lymphatics  of  the  nasal  fossae  enter 
certain  glands  placed  behind  the  pharynx,  in  front  of 
the  rectus  capitis  anticus  major.  Hence,  as  Fraenkel 
has  pointed  out,  "  retro-pharyngeal  abscess  may  arise 
in  consequence  of  diseases  of  the  nose."  Other  lympha- 
tics go  to  the  submaxillary,  parotid,  and  upper  deep 
cervical  lymph  glands,  and  it  is  common  to  find  the 
former  set  of  glands  enlarged  in  nose  affections,  especially 
in  the  scrofulous.  The  lymphatics  of  the  nose  also 
communicate  with  those  of  the  meninges  through  the 
cribriform  plate. 

The  sinuses.— These  may  be  briefly  dealt  with. 
The  frontal  sinuses  (Figs.  13  and  16)  are  not  present 


Chap.  vi.  ]  The  Nasal  Cavities.  93 

in  early  youth,  but  develop  as  age  advances.  They 
do  not  exist  before  the  age  of  ten  years,  but  are  well 
developed  by  twenty.  They  are  formed  by  outgrowths 
of  the  nasal  mucous  membrane,  which  cause  the  diploe 
to  be  absorbed  as  they  advance.  Large  frontal  sinuses 
do  not  necessarily  imply  large  external  prominences 
over  the  glabella  and  superciliary  eminences.  One 
sinus  may  develop  at  the  expense  of  the  other,  and  the 
septum  may  be  displaced  or  absent.  The  body  of  the 
sinuses  lies  behind  the  glabella,  and  they  extend  outwards 
over  the  inner  two-thirds  of  the  orbit  and  backwards 
for  about  \  an  inch.  They  are  larger  in  men  than  in 
women.  They  are  absent  on  one  side  in  25  per  cent, 
of  cases,  and  on  both  sides  in  15  per  cent.  Bony  tumours 
often  grow  from  the  interior  of  these  sinuses,  and  are 
known  as  enostoses.  It  is  obvious  that  a  depressed 
fracture  may  exist  over  a  frontal  sinus  without  the 
cranial  cavity  being  damaged.  In  such  cases  the 
inspissated  contents  of  the  sinus  have  been  mistaken 
for  brain  matter  escaping.  Since  the  sinuses  com- 
municate with  the  nose,  much  emphysema  may  follow 
upon  fracture  of  the  sinus  wall.  Insects  have  found 
their  way  into  these  cavities.  "  Centipedes  are  par- 
ticularly liable  to  be  found  in  the  frontal  sinuses, 
where  they  may  remain  for  years,  the  secretions  of 
these  cavities  furnishing  them  with  sufficient  nourish- 
ment "  (Fraenkel).  Larvse  have  also  been  found  here, 
and  maggots  that  have  developed  within  the  nose  have 
managed  to  make  their  way  to  the  frontal  sinuses. 
A  case  is  reported  where  epistaxis,  extending  over  many 
years,  was  due  to  an  insect  (the  pentastoma  tamioides) 
that  had  settled  in  these  sinuses.  One  day  it  was  sneezed 
out,  and  no  further  bleeding  occurred  (Med.  Times, 
1876).  The  last-named  parasite  is  said  to  be  often  met 
with  in  the  frontal  sinus  of  the  dog.  The  infundibulum 
is  f  of  an  inch  long,  and  runs  downwards  and  slightly 
backwards  to  open  at  the  anterior  end  of  the  hiatus 
semilunaris.  Along  the  hiatus  the  secretion  of  the  frontal 
sinus  is  conveyed  to  the  antrum,  which  in  cases  of  chronic 
inflammation    may    become    a    cesspool   for    the    sinus 


94  Surgical  Applied  Anatomy.      [Chap.  vi. 

(Fig.  16).  The  infundibulum  is  frequently  tortuous,  and 
can  be  catheterised  from  below  with  difficulty  even 
after  the  beak  of  the  middle  turbinate  process  is 
removed.  Hence  in  cases  of  obstruction  the  frontal 
sinus  is  trephined  over  the  glabella,  and  a  probe  passed 
downwards  and  slightly  backwards  to  drain  the  sinus 
into  the  nose.  The  frontal  diploic  vein,  which  joins 
the  frontal  vein  at  the  supraorbital  notch,  receives 
blood  from  the  frontal  sinus.  By  this  channel  infec- 
tion may  be  disseminated  in  the  frontal  bone  from 
disease  of  the  frontal  sinus. 

The  sphenoidal  sinus  opens  on  the  roof  of  the  nose 
behind  the  superior  meatus  (Fig.  16).  It  is  deeply  placed, 
and  not  very  accessible  for  operation  when  the  seat  of 
disease.  The  pituitary  body,  within  the  sella  turcica, 
rests  on  its  roof,  and  tumours  of  this  body  frequently 
invade  the  sinus. 

The  walls  of  the  sinuses  are  thin  and  easily  perforated, 
as  the  following  case,  which  occurred  recently  at  the 
London  Hospital,  will  show.  A  man  stumbled  forwards 
on  his  umbrella  as  he  left  a  public-house  in  Whitechapel, 
the  point  entering  his  face  above  the  bicuspid  teeth. 
He  walked  to  the  hospital,  and  died  three  days  after- 
wards. The  ferrule  of  the  umbrella  was  found  embedded 
in  the  pons,  the  point  having  traversed  the  antrum 
of  Highmore  and  the  sphenoidal  sinus. 

The  antrum  exists  at  birth,  but  attains  its  largest 
dimensions  in  old  age.  The  walls  of  the  cavity  are 
thicker  in  children  than  in  adults.  Tumours  of  various 
kinds  are  apt  to  develop  in  this  cavity,  and  to  distend 
its  walls  in  various  directions.  Thus  the  growth  breaks 
through  the  thin  inner  wall  and  invades  the  nose,  it 
pushes  up  the  roof  of  the  cavity  and  invades  the  orbit, 
it  encroaches  upon  the  mouth  through  the  floor  of 
the  antrum,  and  makes  its  way  also  through  the  some- 
what slender  anterior  wall  into  the  cheek.  The  densest 
part  of  the  antrum  wall  is  that  in  relation  to  the  malar 
bone,  and  this  part  does  not  yield.  There  is  little 
inducement  for  any  growth  to  spread  backwards, 
although  it  sometimes  invades  the  zygomatic  and  pterygo- 


Chap,  vii.]  The  Face.  95 

maxillary  fossae.  As  the  infraorbital  nerve  runs  along 
the  roof  of  the  antrum,  while  the  nerves  of  the  upper 
teeth  are  connected  with  its  walls,  these  structures  are 
pressed  upon  in  growths  springing  from  the  antrum,  and 
much  neuralgia  of  the  face  and  teeth  is  often  produced. 
In  tapping  the  antrum  a  spot  is  usually  selected  just 
above  the  second  bicuspid  tooth,  since  the  bone  is  here 
thin  and  is  conveniently  reached.  In  some  cases  it  is 
sufficient  to  extract  a  molar  tooth,  since  the  fangs  of 
these  teeth  often  enter  the  cavity  of  the  antrum.  The 
teeth  usually  selected  are  either  the  first  or  the  third 
molar.  Not  unfrequently  the  antrum  communicates 
at  its  upper  anterior  part  with  the  frontal  sinus. 

As  the  result  of  a  fall,  one  of  the  upper  teeth  has 
been  entirely  driven  into  the  antrum  and  lost  to  view. 
In  one  case,  reported  by  Haynes  Walton,  an  upper 
incisor  was  found  lying  loose  in  the  antrum  three  and 
a  half  rears  after  the  accident  that  had  driven  it  there. 


CHAPTER    VII. 

THE   FACE. 

The  parts  of  the  face,  other  than  those  already  dealt 
with,  will  be  considered  under  the  following  heads  : 
(1)  The  face  generally;  (2)  the  parotid  region;  and 
(3)  the  upper  and  lower  jaws  and  parts  connected  with 
them.  The  lips  will  be  considered  with  the  "  cavity 
of  the  mouth  "  (chap.  viii.). 

1.  The  face  generally.— The  skin  of  the  face 
is  thin  and  fine,  and  is  more  or  less  intimately  adherent 
by  a  delicate  subcutaneous  tissue-  to  the  parts  beneath. 
The  skin  generally  is  very  freely  supplied  with 
sebaceous  and  sudoriparous  glands,  and  hence  the  face 
is  very  commonly  the  seat  of  acne,  an  eruption  that 
specially  involves  the  sebaceous  follicles.  It  happens 
from  the  thinness  of  the  skin,  and  from  the  absence  of 
dense  fascia?,  that  facial  abscesses  usually  soon  point 
and  seldom  attain  large  size. 


g6  Surgical  Applied  Anatomy.    [Chap.  vn. 

The  cellular  tissue  of  the  face  is  lax,  and  readily 
lends  itself  to  spreading  infiltrations,  so  that  in  certain 
inflammatory  affections  the  cheeks  and  other  parts  of 
the  face  may  become  greatly  swollen.  In  general  dropsy, 
also,  the  face  soon  becomes  "  puffy,"  the  change  first 
appearing,  as  a  rule,  in  the  lax  tissue  of  the  lower  lid. 
The  skin  over  the  chin  is  peculiarly  dense  and  adherent 
to  the  parts  beneath,  and  in  most  respects  closely  re- 
sembles the  integument  of  the  scalp.  When  such 
parts  of  the  integuments  of  the  face  as  cover  prominent 
bones,  such  as  the  parts  over  the  malar  bone,  the  chin, 
the  upper  lid,  are  struck  by  a  blunt  instrument  or  in 
a  fall,  the  wound  produced  has  often  the  appearance 
of  a  clean  incised  wound,  just  as  obtains  in  contused 
wounds  of  the  scalp. 

The  mobility  of  the  facial  tissues  renders  this  part 
very  suitable  for  the  performance  of  plastic  operations 
of  various  kinds,  and  their  vascularity  generally  insures 
a  ready  and  sound  healing.  Although  there  is  a  large 
quantity  of  fat  in  the  subcutaneous  tissue  in  this  region, 
yet  fatty  tumours  are  singularly  rare  upon  the  face. 
They  appear,  indeed,  to  avoid  this  region.  Thus  M. 
Denay  reports  the  case  of  a  man  who  had  no  less  than 
215  fatty  tumours  over  different  parts  of  his  body,  but 
not  one  upon  his  face.  The  thickness  of  the  tissues  of 
the  cheek  and  lips  favours  the  embedding  of  foreign 
substances  in  those  parts.  Thus,  a  tooth  that  has  been 
knocked  out  has  remained  for  some  time  embedded  in 
the  lip.  Henry  Smith  reports  a  remarkable  case,  where 
he  removed  a  piece  of  tobacco-pipe  3  inches  long  from 
the  cheek,  in  the  tissues  of  which  it  had  been  embedded 
for  several  years.  The  soft  tissues  of  the  cheek  greatly 
favour  the  spread  of  destructive  processes.  Thus  in 
cancrum  oris,  a  form  of  gangrene  of  the  face  attacking 
the  young,  the  whole  cheek  may  be  lost  in  a  few  days. 
Great  contraction  is  apt  to  follow  upon  loss  of  substance 
in  the  cheek,  so  that  in  some  cases  the  jaws  may  be 
firmly  closed,  as  is  seen  after  recovery  from  advanced 
cancrum  oris.  The  face  is  peculiarly  liable  to  be  the 
seat  of  certain  ulcers,  especially  the  rodent  and  lupoid 


Chap,  vii.]  The  Face.  97 

ulcer,  and  is  the  part  most  often  attacked  by  "  malignant 
pustule,"  a  disease  transmitted  to  man  from  cattle 
afflicted  with  a  malady  known  in  this  country  as 
"  murrain,"'  and  in  France  as  "  charbon." 

Blood   supply.— The  tissues  of  the  face  are  very 
vascular,  and  are  liberally  supplied  with  blood-vessels 
in  all  parts.     The  finer  vessels  of  the  skin  often  appear 
permanently  injected  or  varieoso  in  the  drunken,  or  in 
those  who  are  exposed  to  cold,  or  are   the  subjects  of 
certain  forms  of  acne.     Thus,   nsevi,   and  the   various 
forms  of  erectile  tumour,  are  common  about  the  face. 
For  a  like  reason  also  wounds  of  the  fare,  while  they 
may  bleed  readily  when  inflicted,  are  apt  to  heal  with 
singular  promptness  and  accuracy.     All  wounds,  there- 
fore, of  this    part    should    have    their  edges    carefully 
adjusted  as  soon  after  the  accident  as  possible.     Exten- 
sive flaps  of  skin  that  have  been  torn  up  in  lacerated 
wounds  often  retain  their  vitality  in  almost  as  marked 
a  manner  as  do  like  flaps  torn  up  from  the  scalp.     Ex- 
tensive injuries  of  the  face  associated  with  great  loss  of 
substance    are    often    repaired    in    a    most    remarkable 
manner,   as  has   been  illustrated   in    gunshot  Avounds 
where  a  considerable  portion  of  the  face  and  upper  jaws 
has  been  blown  away.     The  low  mortality  after  severe 
injuries  to  the  face  is  due,  however,  not  only  to  the 
excellent  powers  of  repair  the  part  possesses,  but  also  to 
the  fact  that  the  face  contains  no  organs  essential  to 
life,  that  its  bones  are  soft  and  thin  and  do  not  favour 
extensive  splitting,  and  that  there  are  several  passages 
and  cavities  in  the  region  through  which    discharges 
may   escape.     One    of   the    most   terrible    instances    of 
injury  not  immediately  fatal  is  reported  by  Longmore  : 
"  An  officer  of  Zouaves,  wounded  in  the  Crimea,  had 
his  whole  face  and  lower  jaw  carried  away  by  a  ball, 
the  eyes  and  tongue  included,  so  that  there  remained 
only  the  cranium,  supported  by  the  neck  and  spine." 
Ho  lived  twenty  hours. 

The  pulsations  of  the  facial  artery  can  be  best  felt 
at  the  lower  border  of  the  jaw,  where  the  vessel  crosses 
just  in  front  of  the  anterior  border  of  the   masseter 

H 


98 


Surgical  Applied  Anatomy,     [chap.  vii. 


muscle.  It  is  here  covered  only  by  the  integument  and 
platysma,  and  can  be  readily  compressed  against  the 
bone  or  ligatured.  The  anastomoses  of  the  artery 
upon  the  face  are  so  free  that  when  the  vessel  is  divided 
both  ends,  as  a  rule,  require  to  be  secured.  Jhe  facial 
vein  is  only  in  contact  with  the  artery  near  the  lower 
border  of  the  jaw  ;  on  the  face  it  is  separated  from  it 
by  a  considerable  interval.  The  vein  is  not  so  flaccid 
as  are  most  superficial  veins  ;  it  remains  more  patent 
after  section,  it  possesses  no  valves,  and  communicates 
at  one  end  indirectly  with  the  cavernous  sinus,  and  at  the 
other  with  the  internal  jugular  vein  in  the  neck.  This 
vein  has  also  another,  but  less  direct,  communication 
with  the  intracranial  veins.  It  is  as  follows  :  the  facial 
vein  receives  the  "  deep  facial  vein  "  from  the  pterygoid 
plexus,  and  this  plexus  communicates  with  the  cavernous 
sinus  by  means  of  some  small  veins  which  pass  through 
the  foramen  ovale  and  the  fibrous  tissue  of  the  foramen 
lacerum  medius.  These  dispositions  of  the  facial  vein 
may  serve  to  explain  the  mortality  of  some  inflamma- 
tory affections  of  the  part.  Thus  carbuncle  of  the  face 
is  not  unfrequently  fatal  by  inducing  thrombosis  of  the 


Fig.  17.— Showing  the  Development  of  the  Face.      {Modified  from  Merkel.) 

f.s.p..  Part  formed  from  the  frontonasal  process,'  l.,  from  its  lateral  and  m. 
from  its  mesial  parts  ;  max.,  formed  by  the  maxillary  process  ;  max.,  formed 
by  the  mandibular  process. 


Chap,  vu.]  The  Face.  99 

cerebral  sinuses,  and  a  like  complication  may  occur  in 
any  other  diffuse  and  deeply  extending  inflammatory 
condition.  The  unusual  patency  also  of  the  facial  vein 
favours  septic  absorption,  and  its  direct  communication 
with  the  great  vein  in  the  neck  may  explain  those  abrupt 
deaths  from  thrombosis  that  have  followed  upon  the 
injection  of  facial  naevi  in  infants. 

A  reference  to  the  development  of  the  face  assists 
to  explain  the  distribution  of  the  fifth  nerve  and  the 
occurrence  of  certain  abnormalities  (Fig.  17).  The  face 
is  developed  from  five  processes,  a  mesial — the  fronto- 
nasal, and  two  lateral — the  maxillary  and  mandibular. 
The  front o-nasal  process  forms  the  middle  part  of  the 
upper  lip  and  the  nose.  It  may  fail  to  develop  when 
the  condition  of  cyclops  is  produced.  It  springs  from 
the  frontal  region  and  carries  with  it  a  branch  of  the 
first  division  of  the  fifth,  the  nasal  nerve.  The  second 
division  of  the  fifth  is  the  nerve  of  the  maxillary  process, 
while  the  third  is  that  of  the  mandibular. 

Nerve  supply.— The  nerves  of  the  face  are  very 
liberally  distributed,  the  fifth  being  the  sensory  nerve, 
the  facial  the  motor.  It  follows,  from  the  great  number 
of  nerve  filaments  about  the  part,  and  the  extensive 
sensory  nucleus  of  the  fifth  nerve,  that  severe  irritants 
applied  to  the  face  may  set  up  a  widespread  nerve  dis- 
turbance. Dr.  George  Johnson  mentions  a  case  where 
a  piece  of  flint  embedded  in  a  scar  on  the  cheek  set  up 
facial  neuralgia,  facial  paralysis,  and  trismus,  and  induced 
a  return  of  epileptic  attacks.  The  positions  of  the  supra- 
and  infra-orbital  foramina  and  of  the  mental  foramen 
are  indicated  as  follows.  The  supraorbital  foramen  is 
found  at  the  junction  of  the  inner  with  the  middle 
third  of  the  upper  margin  of  the  orbit.  A  straight 
line  drawn  downwards  from  this  point  so  as  to  cross 
the  gap  between  the  two  bicuspids  in  both  jaws  will 
hit  both  the  infraorbital  and  mental  foramina.  The 
infraorbital  foramen  is  a  little  over  -\  of  an  inch  below 
the  margin  of  the  orbit.  The  mental  foramen  in  the 
adult  is  midway  between  the  alveolus  and  the  lower 
border  of  the  jaw,  and  is  a  little  over  \  of  an  inch  below 


ioo  Surgical  Applied  Anatomy.    [Chap.  vti. 

the  cul-de-sac  of  mucous  membrane  between  the  lower 
lip  and  jaw.  At  puberty  the  foramen  is  nearer  to  the 
lower  border  of  the  maxilla,  and  in  old  age  it  is  close 
to  the  alveolus.  The  infraorbital  nerve  has  been  divided 
for  neuralgia  at  its  point  of  exit,  the  nerve  being  reached 
either  by  external  incision  or  through  the  mouth  by 
lifting  up  the  cheek.  In  other  cases  the  floor  of  the 
orbit  has  been  exposed,  the  infraorbital  canal  (the 
anterior  half  of  which  has  a  bony  roof)  has  been  opened 
up,  and  large  portions  of  the  trunk  of  the  nerve  have 
been  in  this  way  resected.  Meckel's  ganglion  has  been 
repeatedly  excised  for  the  relief  of  neuralgia  involving 
the  second  division  of  the  fifth  nerve.  A  triangular 
flap  of  skin  is  turned  up  from  the  front  of  the  cheek, 
and  the  infraorbital  canal  is  exposed.  The  anterior 
wall  of  the  antrum  is  opened  with  a  trephine,  and  the 
bone  is  cut  away  from  the  floor  of  the  infraorbital  groove 
so  that  the  nerve  lying  in  that  canal  is  fully  exposed. 
The  nerve  is  followed  back  to  the  posterior  wall  of  the 
antrum.  This  wall  having  been  trephined,  the  spheno- 
maxillary fossa  is  opened  up  and  Meckel's  ganglion 
exposed.  Beyond  the  ganglion  the  foramen  rotundum 
can  be  made  out.  The  infraorbital  artery  runs  with  the 
nerve,  and  that  vessel,  together  with  its  anterior  dental 
branch  to  the  incisor  and  canine  teeth,  will  probably 
be  divided.  The  infraorbital  vein  ends  in  the  pterygoid 
plexus.  The  ganglion  is  surrounded  by  the  terminal 
branches  of  the  internal  maxillary  artery.  It  is  a  triangular 
body,  with  a  diameter  of  about  -i  of  an  inch.  It  is  a  little 
convex  on  its  outer  side,  and  is  of  a  reddish  colour. 

The  following  are  the  relations  of  the  ganglion  in  the 
spheno-maxillary  fossa  : — 

Above. 
The  second  division  of  the  fifth  nerve. 

Outer  side. 
Termination  of  internal      UlecRel'S 
maxillary  artery.         i  _. 

External  pterygoid         ganglion. 

muscle. 

Behind. 

Vidian  canal. 

Sphenoid  bone. 


Inner  side. 

Yertical  plate  of  palate. 

Sphenopalatine 

foramen. 


Chap,  vn.]  The  Face.  tot 

The  inferior  dental  nerve  has  been  diTided  at  the 
mental  foramen  by  an  incision  made  through  the  mucous 
membrane.  Through  this  incision  the  nerve  can  be 
stretched  and  the  cutaneous  portion  of  it  excised.  Its 
trunk  has  been  reached,  and  a  part  excised,  through 
a  trephine  hole  made  in  the  body  of  the  lower  jaw. 
This  operation,  however,  inflicts  great  damage  upon  the 
.  bone,  and  cannot  be  recommended.  The  artery,  more- 
over, is  liable  to  be  wounded. 

The  nerve  has  been  divided  also  before  its  entry 
into  the  mental  foramen  in  the  following  manner.  The 
mouth  being  held  widely  open,  an  incision  is  made 
from  the  last  upper  molar  to  the  last  lower  molar  just 
to  the  inner  side  of  the  anterior  border  of  the  coronoid 
process.  The  cut  passes  through  the  mucous  membrane 
down  to  the  tendon  of  the  temporal  muscle.  The 
ringer  is  introduced  into  the  incision,  and  passed  between 
the  ramus  of  the  jaw  and  the  internal  pterygoid  muscle 
until  the  bony  point  is  felt  that  marks  the  orifice  of  the 
dental  canal.  The  nerve  is  here  picked  up  with  a  hook, 
isolated,  and  divided. 

The  buccal  nerve  may  be  the  seat  of  severe  neuralgia, 
and  may  be  thus  divided  through  the  mouth  :  "  The 
surgeon  places  the  finger-nail  upon  the  outer  lip  of  the 
anterior  border  of  the  ascending  ramus  of  the  lower  jaw 
at  its  centre,  and  divides  in  front  of  this  border  the  mucous 
membrane  and  the  fibres  of  the  buccinator  vertically. 
He  then  seeks  for  the  nerve,  separating  the  tissues  with 
a  director,  -and  divides  it  "  (Stimson). 

The  trunk  of  the  third  division  of  the  fifth  nerve 
has  been  divided  at  the  foramen  ovale  through  a  flap 
wound  made  in  the  cheek.  Considerable  damage  of 
the  soft  parts  results. 

After  section  of  a  branch  of  the  fifth  nerve  the  area 
of  anaesthesia  is  surprisingly  small.  When  the  first 
or  ophthalmic  division  has  been  cut,  only  a  narrow  strip  of 
skin  above  the  eyebrow  is  destitute  of  the  sense  of  touch, 
while  the  area  insensitive  to  pain  and  temperature 
is  slightly  wider.  Owing  to  the  overlapping  of  neigh- 
bouring nerves  the  area  is  much  less  than  the  anatomical 


102  Surgical  Apt  lied  Anatomy.     [Chap.  vn. 

distribution  of  the  ophthalmic   nerve.     If  the  second 

division  is  cut,  the  area  of  anaesthesia  is  confined  to  a 
narrow  space  between  the  orbit  and  the  mouth  ;  on 
section  of  the  third  division,  to  a  strip  running  down- 
wards in  front  of  the  ear  and  along  the  course  of  the 
lower  jaw  (Head). 

Excision  of  the  Gasserian  ganglion. — For  cases  of 
intolerable  and  intractable  neuralgia  Rose  proposed 
the  excision  of  the  Gasserian  ganglion.  It  is  the  sensory 
ganglion  of  the  fifth  nerve,  and  corresponds  to  the  gang- 
lion on  the  posterior  root  of  a  spinal  nerve.  The  nerve 
fibres  of  the  fifth  necessarily  undergo  degeneration 
when  it  is  excised. 

The  operation  usually  performed  is  the  following  : 
An  omega-shaped  flap  of  skin  is  raised  from  the  temples, 
having  the  zygoma  at  its  base  and  the  temporal  ridge 
at  its  convexity.  The  tissues  are  reflected  down  to  the 
floor  of  the  temporal  fossa.  The  superficial  and  deep 
temporal  vessels  have  to  be  tied.  A  wide  trephine 
opening  is  made  in  the  squamosal  and  great  wing 
of  the  sphenoid  on  a  level  with  the  upper  border 
of  the  zygoma  and  the  dura  mater  exposed.  This  is 
usually  followed  by  a  profuse  haemorrhage  from  the 
middle  meningeal  vessels  which  cross  the  field  of  operation. 
The  dura  mater  and  the  superimposed  temporo-sphenoidal 
lobe  are  raised  from  the  bone,  when  the  third  and  second 
divisions  of  the  fifth  nerve  are  brought  into  view  as 
they  escape  by  the  foramen  ovale  and  foramen  rotundum. 
They  are  seen  to  spring  from  the  Gasserian  ganglion 
situated  over  the  apex  of  the  petrous  bone  and  on  the 
outer  wall  of  the  cavernous  sinus.  The  motor  root 
which  supplies  the  muscles  of  mastication  lies  under 
the  ganglion  and  should  not  be  cut.  The  ganglion 
is  embedded  in  the  dura  mater  and  surrounded  by  a 
prolongation  of  the  subarachnoid  space  (Meckel's  space), 
which  is  necessarily  opened.  Only  the  part  of  the 
ganglion  connected  with  the  second  and  third  divisions 
is  removed,  the  part  connected  with  the  ophthalmic 
division  being  left,  as  it  is  firmly  embedded  in  the  outer 
wall  of  the  cavernous  sinus  and  in  close  proximity  to 


Chap,  vii.]  The  Face.  103 

the  internal  carotid  artery  and  oculomotor  nerves. 
The  hippocarnpal  convolution  containing  the  olfactory 
centres  lies  immediately  over  the  ganglion. 

The  malar  bone.— Such  is  the  firmness  of  this 
hone,  and  so  direct  is  its  connection  with  the  skull, 
that  violent  blows  upon  it  are  very  apt  to  be  associated 
with  concussion.  Resting  as  it  does  upon  compara- 
tively slender  bones,  it  is  very  rare  for  the  malar  bone 
to  be  broken  alone.  It  may,  indeed,  be  driven  into 
the  superior  maxillary  bone,  fracturing  that  structure 
extensively,  without  being  itself  in  any  way  damaged. 
A  fracture  of  the  malar  bone  may  lead  to  an  orbital 
ecchymosis,  precisely  like  that  which  often  attends  a 
fracture  of  the  skull  base. 

2.  The  parotid  region.— The  main  part  of  the 
parotid  gland  is  lodged  in  a  definite  space  behind  the 
ramus  of  the  lower  jaw  (Fig.  18).  This  space  is  increased 
in  size  when  the  head  is  extended,  and  when  the  inferior 
maxilla  is  moved  forwards,  as  in  protruding  the  chin. 
In  the  latter  movement,  the  increase  in  the  antero- 
posterior direction  is  equal  to  about  f  of  an  inch.  It 
is  diminished  when  the  head  is  flexed.  When  the 
mouth  is  widely  opened  the  space  is  diminished  below, 
while  it  is  increased  above  by  the  gliding  forwards  of 
the  condyle.  These  facts  should  be  borne  in  mind 
in  operating  upon  and  in  exploring  the  parotid  space. 
It  will  be  found  also  that  in  inflammation  of  the  parotid 
much  pain  is  produced  by  all  those  movements  that 
tend  to  narrow  the  space  occupied  by  the  gland.  The 
obliquity  of  the  ramus  of  the  jaw  in  infancy  and  old 
age  causes  the  lower] part  of  the  space  to  be,  in  the  former 
instance  relatively  and  in  the  latter  instance  actually, 
larger  than  it  is  in  the  adult. 

The  gland  is  closely  invested  by  a  fascia  derived 
from  the  cervical  fascia.  The  superficial  layer  of  the 
parotid  fascia  is  very  dense,  is  continuous  behind  with 
the  fibrous  sheath  of  the  sterno-mastoid,  and  in  front 
with  that  of  the  masseter.  Above  it  is  attached  to 
the  zygoma,  while  below  it  joins  the  deep  layer.  The 
deep  layer  is  slender,  is  attached  to  the  styloid  process, 


104 


Surgical  Applied  Anatomy.    [Chap.  vii. 


forms   the  stylo-maxillary,  ligament,  and  is  connected 
with   the   sheaths   of   the   pterygoid   muscles   and   the 


Fig.  IS.— A  Horizontal  Section  through  the  Face  and  Neck  just  above 
the  level  of  the  Lower  Teeth  (Braune). 

a,  Orbicularis  oris  and,  behind  it,  the  buccinator ;  A,  internal  pterygoid.;  r,  mas- 
seter ;  d,  styloglossus,  stylo-pharyngeus,  and  styloid  process;  e,  Splenitis 
capitis ;/,  digastric. ;  ci,  sterno-mastoid ;  k,  obliquus  superior;  i,  trachelo- 
mastoid  ;  j,  biventer  cervicis  and  coiuplexus  ;  k,  trapezius;  I.  tonsil ;  ?/i, facial 
artery  ;  n,  facial  vein  ;  o,  gustatory  nerve  ;  p,  inferior  dental  nerve  and  artery  ; 
g,  styloid  process  ;  r,  external  carotid  artery  ;  s,  internal  carotid  artery  ; 
t,  vagus  ;  u\  parotid  gland  ;  :r,  internal  jugular  vein,  \\\t\i  the  vagus,  spinal 
accessory,  and  hypo-glossal  nerves  to  its  inner  side;  y,  vertebral  artery; 
z,  odontoid  process;  1,  occipital  artery. 


chap,  vii.]  The  Face.  T05 

pterygoid    process.     The    gland    is,    therefore,    encased 

in  a  distinct  sac  of  fascia,  which  is  entirely  closed  below, 
but  is  quite  open  above.  Between  the  anterior  edge 
of  the  styloid  process  and  the  posterior  border  of  the 
external  pterygoid  muscle  there  is  a  gap  in  the  fascia, 
through  which  the  parotid  space  communicates  with 
the  connective  tissue  about  the  pharynx.  It  is  well 
known  that  in  post-pharyngeal  abscesses  there  is  very 
usually  a  parotid  swelling,  and  in  several  instances 
the  pus,  or  at  least  some  portion  of  it,  has  been  evacuated 
in  the  parotid  region.  In  these  cases  the  matter  most 
probably  extends  from  the  pharyngeal  to  the  parotid 
region  through  the  gap  just  described.  From  the 
disposition  of  the  fascia  it  follows  that  very  great 
resistance  is  offered  to  the  progress  of  a  parotid  abscess 
directly  outwards  through  the  skin.  The  abscess  often 
advances  upwards  to  the  temporal,  or  zygomatic  fossae, 
in  the  direction  of  least  resistance,  although  progress 
in  that  line  is  resisted  by  gravity.  It  frequently  makes 
its  way  towards  the  buccal  cavity  or  pharynx,  or  it  may 
break  through  the  lower  limits  of  the  fascia  and  reach 
the  neck.  It  must  be  borne  in  mind  that  the  gland 
is  in  direct  contact  with  the  cartilaginous  meatus,  with 
the  ramus  of  the  jaw  and  other  bony  parts,  and  is  closely 
related  with  the  temporo-maxillary  joint.  Thus,  a 
parotid  abscess  has  burst  into  the  meatus,  has  led  to 
periostitis  of  the  bones  adjacent  to  it,  and  has  incited 
inflammation  in  the  joint  of  the  lower  jaw. 

In  several  cases  reported  by  Virchow  the  pus  appears 
to  have  found  its  way  into  the  skull  along  branches 
of  the  fifth  nerve,  for  the  environs  of  the  Gasserian 
ganglion  were  found  infiltrated  with  pus.  The  auriculo- 
temporal and  great  auricular  nerves  supply  the  gland 
with  sensation,  and  the  presence  of  these  nerves,  to- 
gether with  the  unyielding  character  of  the  parotid 
fascia,  serves  to  explain  the  great  pain  felt  in  rapidly 
growing  tumours  and  acute  inflammation  of  the  gland. 
The  pain  is  often  very  distinctly  referred  along  the  course 
of  the  auriculotemporal  nerve.  Thus,  a  patient  with 
parotid  growth    recently  under  my  care    had    pain   in 


106  Surgical  Applied  Anatomy.     [Chap.  vn. 

those  parts  of  the  pinna  and  temple  supplied  by  the  nerve, 
pain  deep  in  the  meatus,  at  a  spot  that  would  correspond 
to  the  entrance  of  the  meatus  branch  of  the  nerve,  and 
pain  in  the  joint  of  the  lower  jaw,  which  is  supplied  by 
the  auricalo-temporal. 

The  most  important  structures  in  the  gland  are  the 
external  carotid  artery,  with  its  two  terminal  branches, 
and  the  facial  nerve.  The  artery,  as  Tillaux  has  pointed 
out,  is  behind  the  ramus  of  the  jawr,  as  high  up  as  the 
junction  of  the  inferior  with  the  middle  third  of  its 
posterior  border.  It  then  enters  the  parotid  gland, 
and,  passing  a  little  backwards  and  outwards,  comes 
nearer  to  the  surface,  and  at  the  level  of  the  condyle  of 
the  jaw  breaks  into  its  two  terminal  branches.  The 
artery,  therefore,  does  not  enter  the  gland  at  its  inferior 
border,  and  is  not  in  actual  relation '  with  the  parotid 
space  at  its  lowest  part.  The  vessel,  moreover,  is  not 
parallel  with  the  edge  of  the  ramus,  but  passes  through 
the  parotid  gland  with  some  obliquity. 

The  facial  nerve  is  represented  by  a  line  drawn 
across  the  gland,  in  a  direction  forwards  and  a  little 
downwards  from  the  spot  where  the  anterior  border  of 
the  mastoid  process  meets  the  ear.  The  nerve  is  not 
quite  so  intimately  bound  up  in  the  gland  as  is  the  carotid 
artery,  and  in  rapidly  growing  tumours  of  the  gland 
facial  paralysis  from  pressure  upon  this  nerve  is  not 
uncommon. 

The  nerve  has  been  stretched  close  to  its  point  of  exit 
from  the  stylo-mastoid  foramen  for  the  relief  of  facial 
tic.  It  is  best  found  at  a  spot  about  \  of  an  inch  in 
front  of  the  centre  of  the  anterior  border  of  the  mastoid 
process.  It  will  be  found  above  the  posterior  belly  of 
the  digastric,  which  serves  as  a  guide  to  it  in  the  depth 
of  the  wound. 

It  follows,  from  the  complex  relations  of  the  parotid, 
that  its  entire  removal  as  a  surgical  procedure  is  an 
anatomical  impossibility.  In  opening  a  parotid  abscess 
a  cut  is  usually  made  over  the  angle  of  the  jaw,  and 
a  director  pushed  upwards  into  the  substance  of  the 
gland,   after  the   plan  advised   by  Hilton.     The  gland 


Chap.  vii. i  The  Face.  107 

is  separated  by  a  mere  layer  of  fascia  from  tli^  internal 
carotid  artery,  the  internal  jugular  vein,  the  vagus, 
glossopharyngeal,  and  hypoglossal  nerves  (Fig.  18). 
Thus,  in  stabs  in  the  parotid  region  it  may  be  difficult 

at  first  to  tell  whether  the  internal  or  the  external  caro- 
tid is  wounded.  It  has  been  suggested  that  the  cerebral 
hyperemia  sometimes  noticed  in  severe  parotitis 
(mumps)  may  be  due  to  the  pressure  of  the  enlarged 
gland  upon  the  internal  jugular  vein. 

Tumours  of  the  parotid  are  very  apt  to  contain  car- 
tilaginous tissue.  It  is  well  known  that  metastases 
after  mumps  are  quite  common  in  the  testis.  It  is 
significant  in  this  connection  that  the  testis  is  one  of  the 
few  parts  of  the  body,  apart  from  bone,  where  carti- 
laginous matter  forms  a  frequent  constituent  of  the 
neoplasms  of  the  part.  Mr.  Paget  lias  pointed  out  that 
inflammation  of  the  parotid  is  peculiarly  frequent  after 
injuries  and  diseases  of  the  abdomen  and  pelvis.  It 
occurs  also  very  often  as  a  sequela  of  some  specific  fevers, 
but  more  especially  after  typhoid.  The  anatomical  or 
physiological  basis  of  this  connection  has  not  been  made 
out. 

Many  lymphatic  glands  are  placed  upon  the  surface 
and  in  the  substance  of  the  parotid  gland.  They  receive 
lymph  from  the  frontal  and  parietal  regions  of  the  scalp, 
from  the  orbit,  the  posterior  part  of  the  nasal  fossa?, 
the  upper  jaw,  and  the  hinder  and  upper  part  of  the 
pharynx.  When  enlarged  these  glands  may  form  one 
species  of "  parotid  tumour." 

Stenson's  duct  is  about  two  and  a  half  inches 
long,  and  has  a  diameter  of  §th  of  an  inch,  its 
orifice  being  the  narrowest  part.  At  the  anterior 
border  of  the  masseter  muscle  the  duct  bends  suddenly 
inwards  to  pierce  the  buccinator  muscle.  The  bend  is 
so  abrupt  that  the  buccal  segment  of  the  duct  may 
be  almost  at  right  angles  with  the  masseteric.  This 
bend  should  be  taken  into  consideration  in  passing  a 
probe  along  the  duct  from  the  mouth.  The  duct  opens 
on  the  summit  of  a  papilla  placed  on  a  level  with  the 
second  upper  molar  tooth.     The  course  of  the  duct  across 


io8  Surgical  Applied  Anatomy.     [Chap. yit. 

the  masseter  is  represented  by  a  line  drawn  from  the 
lower  margin  of  the  concha  to  a  point  midway  between 
the  ala  of  the  nose  and  the  red  margin  of  the  lip.  It  lies 
about  a  finger-breadth  below  the  zygoma,  having  the 
transverse  facial  artery  above  it  and  the  infra-orbital 
branches  of  the  facial  nerve  below  it.  The  duct  has 
been  ruptured  subcutaneously,  leading  to  extravasations 
of  saliva.  Wounds  of  the  duct  are  apt  to  lead  to 
salivary  fistula?.  When  the  fistula  involves  the  buccal 
segment  of  the  duct  it  may  be  cured  by  opening  the 
duct  into  the  mouth  on  the  proximal  side  of  the  fistula. 
Fistulae  of  the  masseteric  segment  are,  on  the  other 
hand,  very  difficult  to  relieve.  At  least  one-half  of  the 
buccal  part  of  the  duct  is  embedded  in  the  substance 
of  the  buccinator  muscle.  A  salivary  fistula  over  the 
masseter  may  involve  the  parotid  gland  itself,  or 
that  part  of  it  known  as  the  socia  parotidis.  Inflamma- 
tory conditions  may  spread  to  the  parotid  from  the 
mouth  along  Stenson's  duct. 

3.  The  upper  and  lower  jaws,  and  parts 
connected  with  them. 

The  superior  maxilla  (for  antrum,  see  Nose, 
page  93  ;  for  hard  palate,  see  Mouth,  page  127). — 
This  bone,  on  account  of  its  fragility  and  the  manner 
in  which  it  is  hollowed  out,  is  very  readily  fractured. 
The  fracture  may  be  due  to  direct  violence,  as  by  a  blow 
from  a  "  knuckle-duster,"  or  it  may  be  broken  by  a  force, 
transmitted  from  the  lower  jaw  through  the  teeth,  as  in 
cases  of  severe  blows  or  falls  upon  the  chin.  It  may  be 
broken  by  a  blow  upon  the  head,  when  the  chin  is  fixed, 
no  other  bone  being  damaged  ;  and,  lastly,  it  may  be 
crushed,  as  above  stated,  by  the  driving  in  of  the  malar 
bone.  The  displacement  of  the  fragments  depends 
upon  the  direction  and  degree  of  the  force  employed, 
no  muscles  having  effect.  The  bone  being  very  vascular, 
serious  injuries,  involving  great  loss  of  substance,  are 
often  wonderfully  repaired.  Its  hollowness  and  the 
cavities  that  it  helps  to  bound  render  it  possible  for 
large  foreign  bodies  to  be  retained  in  the  deeper  parts 
of   the   face.     Thus,    Longmore    reports    "  the    case    of 


Chap,  vil]  The  Face.  109 

Lieutenant  Fretz,  of  the  Ceylon  Rifles,  who  was  able  to 
do  his  military  duties  for  nearly  eight  years  with  the 
breech  and  screw  of  a  burst  musket  lodged  in  the  nares, 
part  of  the  tail-pin  and  screw  protruding  through  the 
hard  palate  into  the  mouth."  The  bone  may  undergo 
extensive  necrosis,  especially  in  that  form  of  necrosis 
induced  in  workers  in  match  factories  by  exposure  to  the 
fumes  of  phosphorus.  In  one  case  (Med.  Times,  1862) 
of  necrosis  following  measles  the  mischief  was  limited 
to  the  pre-maxillary,  or  incisive  bone. 

The  periosteum  of  the  superior  maxilla  is,  lil<r'  the 
pericranium,  not  disposed  to  form  new  bone.  In  or- 
dinary cases  of  necrosis  of  the  upper  jaw  no  reproduction 
of  bone  takes  place,  the  gap  being  left  permanent.  In 
the  lower  jaw  abundant  new  bone  is  produced  by  the 
periosteum,  and  extensive  losses  may  be  repaired.  It  is 
remarkable,  however,  that  in  course  of  years  this  new 
bone  is  liable  to  be  very  extensively  reabsorbed. 

Excision  of  the  superior  maxilla. — The 
entire  bone  has  been  frequently  removed  when  the 
seat  of  an  extensive  tumour,  and  under  certain  other 
conditions.  The  bony  connections  to  be  divided  in  the 
operation  are  the  following  :  (1)  The  connection  with 
the  malar  bone  at  the  outer  side  of  the  orbit ;  (2)  the 
connection  of  the  nasal  process  with  the  frontal,  nasal, 
and  lachrymal  bones  ;  (3)  the  connections  of  the  orbital 
plate  with  the  ethmoid  and  palate  (this  plate  is  often 
left  behind,  or  is  cut  through  near  the  orbital  margin) ; 
(4)  the  connection  with  the  opposite  bone  and  the  palate 
in  the  roof  of  the  mouth  ;  and  (5)  the  connection  behind 
with  the  palate  bone,  and  the  fibrous  attachments  to 
the  pterygoid  processes.  In  the  four  first-named  in- 
stances the  separation  is  effected  by  a  cutting  instrument  ; 
in  the  last-named,  by  simply  twisting  out  the  bone. 
Soft  parts  divided  :  These  may  be  considered  under 
three  heads  :  The  parts  cut  (1)  in  the  first  incision  ; 
(2)  in  turning  back  the  flap  ;  and  (3)  in  separating 
the  bone. 

(1)  The'following  are  the  parts  cut  in  order  from 
above  downwards  in  the  usual,  or  "  median,"  incision. 


no  Surgical  Applied  Anatomy.     [Chap. vii. 

an  incision  commencing  parallel  with  the  lower 
eyelid,  and  continued  down  the  side  of  the  nose, 
round  the  ala,  and  through  the  middle  of  the  upper 
lip :  Skin,  superficial  fascia,  orbicularis  palpebrarum, 
palpebral  branches  of  infraorbital  nerve  and  artery, 
part  of  lev.  labii  superioris,  angular  artery  and  vein, 
lev.  labii  sup.  alaeque  nasi,  lateralis  nasi  artery  and 
vein,  nasal  branches  of  infraorbital  nerve,  compressor 
naris,  depressor  alae  nasi,  attachment  of  nasal  cartilage 
to  bone,  orbicularis  oris,  sup.  coronary  artery  and  vein, 
and  mucous  membrane  of  lip.  Various  branches  of 
the  facial  nerve  to  the  muscles  may  be  cut.  (2)  In 
turning  back  the  flap,  the  muscles  above  named  will 
be  dissected  up,  together  with  the  tendo  oculi,  if  the 
nasal  process  is  removed  entire,  the  levator  anguli,  the 
buccinator,  a  few  fibres  of  the  masseter,  and,  on  the 
orbital  plate,  the  inferior  oblique  muscles.  The  infra- 
orbital nerve  and  artery  will  be  cut  as  they  leave  their 
foramen.  In  the  flap  itself  will  be  the  trunks  of  the 
facial  artery  and  vein,  the  transverse  facial  artery,  and 
the  facial  part  of  the  facial  nerve.  (3)  In  separating 
the  nasal  process  the  lachrymal  sac  and  infratrochlear 
nerve  will  be  damaged,  and  the  nasal  duct  and  external 
branch  of  the  nasal  nerve  cut  across.  In  separating 
the  bones  below,  the  coverings  of  the  hard  palate  are 
divided,  and  the  attachment  of  the  soft  palate  to  the 
palate  bone,  unless  the  removal  of  that  process  can  be 
avoided.  "  Any  attempt  to  dissect  off  and  preserve 
the  soft  covering  of  the  hard  palate  is  futile  "  (Heath). 
Posteriorly,  the  trunk  >of  the  infraorbital  nerve  is  again 
divided  (this  time  in  front  of  Meckel's  ganglion),  together 
with  the  posterior  dental  and  infraorbital  arteries,  and 
some  branches  of  the  spheno-palatine  artery.  The 
deep  facial  vein  from  the  pterygoid  plexus  will  probably 
be  cut,  and,  lastly,  near  the  palate  will  also  be  divided 
the  large  palatine  nerve  and  the  descending  palatine 
artery. 

It  will  be  seen  that  no  large  artery  is  divided  in  the 
operation.  The  inferior  turbinated  bone  comes  away  of 
course,  with  the  maxilla. 


Chap,  vii.]  The   Face.  hi 

The  inferior  maxilla;  fracture.  -This  bone 
is  to  a  great  extent  protected  from  fracture  by  its  horse- 
shoe shape,  which  gives  it  some  of  the  properties  of  a 
spring,  by  its  density  of  structure,  by  its  great 
mobility,  and  by  the  buffer-like  interarticular  carti- 
lages that  protect  its  attached  extremities.  The  bone 
is  usually  broken  by  direct  violence,  and  the  fracture 
may  be  in  any  part.  The  symphysis  is  rarely  broken, 
on  account  of  its  great  thickness.  The  ramus  is  pro- 
tected by  the  muscular  pads  that  envelop  its  two  sides, 
and  the  coronoid  process  is  still  more  out  of  the  risk  of 
injury,  owing  to  the  depth  at  which  it  is  placed  and  the 
protection  it  derives  from  the  zygoma,  The  weakest  part 
of  the  bone  is  in  front,  where  its  strength  is  diminished 
by  the  mental  foramen  and  by  the  large  socket  required 
for  the  canine  tooth.  It  is  about  this  part,  therefore, 
that  fracture  is  the  most  common.  The  bone  may  be 
broken  near,  or  even  through,  the  symphysis  by  indirect 
violence,  as  by  a  blow  or  crushing  force  that  tends  to 
approximate  the  two  rami.  Thus,  the  jaw  has  been 
broken  near  the  middle  line  by  a  blow  in  the  masseteric 
region.  The  amount  of  displacement  in  fractures  of 
this  bone  varies  greatly,  and  is  much  influenced  by  the 
nature  and  direction  of  the  force.  In  general  terms,  it 
may  be  said  that  when  the  body  of  the  bone  is  broken 
the  anterior  fragment  is  drawn  backwards  and  down- 
wards by  the  jaw  depressors,  the  digastric,  mylo-hyoid, 
genio-hyoid,  and  genio-hyo-glossus  ;  while  the  hinder 
fragment  is  drawn  up  by  the  elevators  of  the  jaw,  the 
masseter,  internal  pterygoid,  and  temporal.  It  must  be 
remembered  that  the  mylo-hyoid  muscle  will  be  attached 
to  both  fragments,  and  will  modify  the  amount  of  dis- 
placement. Fractures  of  the  ramus  are  seldom  attended 
with  much  displacement,  muscular  tissue  being  nearly 
equally  attached  to  both  fragments. 

In  fractures  of  the  body  of  the  bone  the  dental 
nerve  often  marvellously  escapes  injury,  a  fact  that  is 
explained  by  the  supposition  that  the  bones  are  not 
usually  sufficiently  displaced  to  tear  across  the  nerve. 
Weeks  after  the  accident,  however,  the  nerve  has  become 


i  j  2  Surgical  Applied  Anatomy.     [Chap.  vii. 

so  compressed  by  the  developing  callus  as  to  have  its 
function  destroyed. 

One,  or  both,  condyles  have  often  been  broken  by 
falls  or  blows  upon  the  chin.  The  gums  being  firm 
and  adherent,  it  follows  that  they  are  usually  torn  in 
fractures  of  the  body  of  the  maxilla,  and  hence  the  bulk 
of  the  fractures  in  this  part  are  compound. 

The  temporo  -  maxillary  articulation  is 
supported  by  a  capsule  which  varies  greatly  in  thick- 
ness in  different  parts.  By  far  the  thickest  part  of 
the  capsule  is  the  external  part  (the  external  lateral 
ligament).  The  internal  part  is  next  in  thickness, 
while  the  anterior  and  posterior  portions  of  the  capsule 
are  thin,  especially  the  former,  which  is  very  thin. 
Thus,  when  this  joint  suppurates,  the  pus  is  least 
likely  to  escape  on  the  external  aspect  of  the  articula- 
tion, and  is  most  likely  to  find  an  exit  through  the 
anterior  part  of  the  capsule,  although  this  part  is  to  a 
great  extent  protected  by  the  attachments  of  the  ex- 
ternal pterygoid  muscle.  Immediately  behind  the 
condyle  of  the  jaw  are  the  bony  meatus  and,  a  little  to 
the  inner  side,  the  middle  ear.  In  violent  blows  upon 
the  front  of  the  jaw  these  structures  may  be  damaged, 
and  it  is  interesting  to  note  that  the  strongest  ligament 
of  the  joint  (the  external  lateral)  has  a  direction  down- 
wards and  backwards,  so  as  to  immediately  resist  any 
movement  of  the  condyle  towards  the  slender  wall  of 
bone  that  bounds  the  meatus  and  tympanum.  Were  it 
not  for  this  ligament,  a  blow  upon  the  chin  would  be 
a  much  more  serious  accident  than  it  is  at  present. 

It  follows,  from  the  proximity  of  the  joint  to  the 
middle  ear,  that  disease  in  the  articulation  may  be  set 
up  by  suppuration  in  this  part.  In  one  case  (Holmes' 
"  System  of  Surgery  "),  suppurative  disease,  spreading 
from  the  middle  ear,  not  only  involved  the  joint,  but 
induced  necrosis  of  the  condyle  of  the  lower  jaw.  The 
necrosed  condyle  was  removed  entire  from  the  auditory 
meatus,  into  which  cavity  it  had  projected. 

Dislocation. — This  joint  permits  only  of  one 
form   of   dislocation,   a   dislocation   forwards.     It   may 


Chap,  vii.]  The   Face.  t  t  3 

be  unilateral  or  bilateral,  blie  latter  being  the  mere 
usual,  and  it  can  only  occur  when  the  mouth  happens 
to  be  wide  open.  Indeed,  the  dislocation  is  nearly  always 
due  to  spasmodic  muscular  action  when  the  mouth 
is  open,  although  in  some  few  cases  it  has  been  brought 
about  by  indirect  violence,  as  by  a  downward  blow 
upon  the  lower  front  teeth,  the  mouth  being  widely 
opened.  It  has  occurred  during  yawning,  violent 
vomiting,  etc.  In  more  than  one  case  the  accident 
happened  while  a  dentist  was  taking  a  cast  of  the  mouth. 
Hamilton  quotes  a  bilateral  dislocation  in  a  woman 
during  the  violent  gesticulations  incident  to  the  pursuit 
of  scolding  her  husband.  When  the  mouth  is  widely 
opened,  the  condyles,  together  with  the  interarticular 
fibro-cartilage,  glide  forward.  The  fibro-cartilage 
extends  as  far  as  the  anterior  edge  of  the  eminentia 
articularis,  which  is  coated  with  cartilage  to  receive  it. 
The  condyle  never  reaches  quite  so  far  as  the  summit 
of  that  eminence.  All  parts  of  the  capsule  save  the 
anterior  are  rendered  tense.  The  coronoid  process  is 
much  depressed.  Xow  if  the  external  pterygoid  muscle 
(the  muscle  mainly  answerable  for  the  luxation)  contract 
vigorously,  the  condyle  is  soon  drawn  over  the  eminence 
into  the  zygomatic  fossa,  the  interarticular  cartilage 
remaining  behind.  On  reaching  its  new  position  it  is 
immediately  drawn  up  by  the  temporal,  internal  ptery- 
goid, and  masseter  muscles,  and  is  thereby  more  or  less 
fixed.  A  specimen  in  the  Musee  Dupuytren  shows 
that  the  fixity  of  the  luxated  jaw  may  sometimes  depend 
upon  the  catching  of  the  apex  of  the  corf  moid  process 
against  the  malar  bone. 

Subluxation  of  the  jaw  is  a  name  given  to  a 
slight  and  quite  incomplete  dislocation  of  the  jaw  not 
infrequently  met  with  in  delicate  women.  It  is  due 
to  a  displacement  of  the  interarticular  cartilage,  and 
can  be  cured  by  exposing  the  cartilage  and  attaching 
it  by  suture  to  the  fibrous  structures  around  the  joint 
(Annandale). 

Excision     of    the    inferior    maxilla.— Con- 
siderable portions  of  the  lower  jaw  can  be  excised  through 


ii4  Surgical    Applied   Anatomy.     [Chap.  vii. 

the  mouth  without  external  wound.  In  excising  one 
entire  half  of  the  maxilla  a  cut  is  made  vertically  through 
the  lower  lip  down  to  the  point  of  the  chin,  and  is  then 
continued  back  along  the  inferior  border  of  the  jaw, 
so  as  to  end  near  the  lobule  of  the  ear,  after  having  been 
carried  vertically  upwards  in  the  line  of  the  posterior 
border  of  the  ramus.  The  soft  parts  divided  may  be 
considered  under  three  heads  :  Those  concerned  (1)  in 
the  first  incision  ;  (2)  in  clearing  the  outer  surface  of 
the  bone  ;  (3)  in  clearing  the  inner  surface  of  the 
bone. 

1.  (a)  In  the  anterior  vertical  cut :  Skin,  etc., 
orbicularis  oris,  inferior  coronary  and  inferior  labial 
vessels,  branches  of  submental  artery,  levator  menti, 
mental  vessels  and  nerve,  some  radicles  of  anterior 
jugular  vein.  (6)  In  the  horizontal  cut :  Skin,  etc.,  pla- 
tysma,  branches  of  superficial  cervical  nerve,  branches 
of  supra-maxillary  part  of  facial  nerve,  facial  artery  and 
vein  at  edge  of  masseter,  and  inframaxillary  branch 
of  facial  nerve  (not  necessarily  divided),  (c)  The  pos- 
terior vertical  incision  would  not  go  down  to  the  bone, 
and  would  merely  expose  the  surface  of  the  parotid 
gland  and  part  of  posterior  border  of  masseter 
muscle. 

2.  In  clearing  the  outer  surface  the  following  parts 
are  dissected  back  :  Levator  menti,  the  two  depressor 
muscles,  buccinator,  masseter  (crossed  by  part  of  parotid 
gland,  transverse  facial  vessels,  facial  nerve  and  Stenson's 
duct),  masseteric  vessels  and  nerve,  temporal  muscle. 

3.  In  clearing  the  inner  surface  :  Digastric,  genio- 
hyoid, genio-hyo-giossus,  and  mylo-hyoid  muscles,  a 
few  fibres  of  superior  constrictor,  internal  pterygoid 
muscle,  inferior  dental  artery  and  nerve,  mylo-hyoid 
vessels  and  nerve,  internal  lateral  ligament,  rest  of  in- 
sertion of  temporal  muscle,  mucous  membrane. 

Parts  in  risk  of  being  damaged. — The  facial  nerve, 
if  the  posterior  vertical  incision  be  carried  too  high  up. 
The  internal  maxillary  artery,  temporo-maxillary  vein, 
auriculo-temporal  nerve  (structures  all  closely  related 
to  the  .jaw  condyle),   external   carotid  artery,   lingual 


chap,  vii.]  The   Face.  115 

nerve,  the  parotid,  .submaxillary,  and  .sublingual  glands. 
After  subperiosteal  resection  the  entire  bone  lias  been 
reproduced. 

Deformities.— The    lower   jaw  may   be   entirely 

absent,  or  may  be  of  dwarfed  dimensions,  or  be  incom- 
pletely formed.  These  conditions  are  congenital,  and 
depend  upon  the  defective  development  of  the  mandibular 
or  first  visceral  arch,  out  of  which  the  lower  jaw  is  formed 
(Fig.  17).  They  are  often  associated  with  branchial 
fistuke,  supernumerary  ears,  macrostoma,  and  like 
congenital  malformations. 

With  regard  to  the  nerves  connected  with  the 
jaws,  little  need  be  said.  The  upper  teeth  are  supplied 
by  the  second  division  of  the  fifth,  the  lower  by  the 
third.  Some  remarkable  nerve  disturbances  have 
followed,  by  reflex  action,  upon  irritation  of  the  dental 
nerves.  Thus  cases  of  strabismus,  temporary  blindness, 
and  wry-neck  have  been  reported  as  due  to  the  irritation 
of  carious  teeth.  Hilton  gives  the  case  of  a  man  who 
was  much  troubled  by  a  carious  tooth  in  the  lower  jaw 
(supplied  by  the  third  division  of  the  fifth),  and  who 
developed  a  patch  of  grey  hair  over  the  region  supplied 
by  the  auriculo-temporal  nerve  (a  branch  also  of  the 
third  division). 

Caries  of  the  teeth  is  frequently  associated  with  areas 
of  hyperesthesia  on  the  side  of  the  face  and  neck.  The 
dental  and  cutaneous  nerves  of  these  areas  are  connected 
centrally,  and  to  these  areas  pain  is  referred.  Disease 
of  the  peri-dental  membrane  does  not  give  rise  to  referred 
pains  (Head). 

The  mtiseles  ot  mastiea tion  are  often  attacked 
by  spasm.  When  the  spasm  is  clonic  the  chattering 
of  the  teeth  is  produced  that  is  so  conspicuous  a  feature 
in  rigor.  When  the  spasm  is  tonic  the  mouth  is  rigidly 
closed,  and  the  condition  known  as  trismus,  or  lockjaw, 
is  produced.  Trismus  is  amongst  the  first  symptoms 
of  tetanus.  It  is  also  very  apt  to  be  produced  by  irrita- 
tion of  any  of  the  sensory  branches  of  the  third  division 
of  the  fifth,  since  the  motor  nerve  supply  of  the  muscles 
themselves  is  derived  from  that  trunk.     Thus  trismus 


n6  Surgical   Applied   Anatomy.     [Chap. vn. 

is  very  common  in  caries  of  the  lower  teeth,  and  during 
the  "  cutting "  of  the  lower  wisdom  tooth.  It  is  much 
less  common  in  affections  of  the  upper  set  of  teeth,  since 
they  are  supplied  by  a  more  remote  division  of  the  fifth 
nerve. 

Teeth.— As  a  test  of  age  the  following  periods 
for  the  eruption  of  teeth  are  given  by  Mr.  C.  Tomes  : 
Temporary  teeth  :  Lower  central  incisors,  six  to  nine 
months  ;  upper  incisors,  ten  months ;  lower  lateral 
incisors,  and  four  first  molars,  a  few  months  later ; 
then,  after  a  rest  of  four  or  five  months,  the  canines  ; 
and,  lastly,  the  second  molars  ;  the  whole  being  in  place 
by  the  end  of  the  second  year.  Permanent  teeth  :  First 
molars,  sixth  or  seventh  year  ;  next  in  order  the  lower 
central  incisors,  then  the  upper  central  incisors,  and  a 
little  later  the  laterals,  the  eighth  year  ;  first  bicuspids, 
ninth  or  tenth  year  ;  second  bicuspids  and  canines, 
about  the  eleventh  year,  the  lower  preceding  the  upper  ; 
the  second  molars,  the  twelfth  or  thirteenth  year  ;  the 
wisdom  teeth,  eighteen  to  twenty-five  or  later. 

An  alveolar  abseess  is  an  abscess  about  the 
fang  of  a  tooth.  In  the  case  of  single-fanged  teeth 
the  pus  may  escape  along  the  groove  of  the  fang.  With 
other  teeth  the  pus  tends  to  pierce  the  alveolus.  If  the 
point  of  the  fang  is  within  the  reflection  of  the  mucous 
membrane  from  the  gum  to  the  cheek  the  abscess  will 
break  into  the  mouth,  but  if  the  point  of  the  fang  is 
without  that  reflection,  or  if  the  pus  can  gravitate  with- 
out the  line  of  the  reflection,  then  the  pus  may  break 
through  the  cheek.  Alveolar  abscess  of  the  upper  incisors 
and  canines  never  breaks  through  the  cheek.  When  con- 
nected with  the  upper  molars  it  sometimes  does.  When 
connected  with  any  of  the  lower  teeth  the  abscess  may 
find  its  way  through  the  skin  of  the  cheek. 

The  upper  wisdom  tooth  is  developed  in  the  pos- 
terior border  of  the  upper  jaw,  and  the  lower  wisdom 
on  the  inner  aspect  of  the  ascending  ramus.  They  may 
fail  to  come  into  position  or  remain  buried.  They  may 
give  rise  to  an  abscess  which  frequently  points  in  the  neck, 
at  some  distance  from  its  seat  of  origin. 


1 1 


CHAPTER    VIII. 

THE    MOUTH,    TONGUE,    PALATE,    AND    PHARYNX. 

The    lips. — The  principal    tissues    composing    the 

lips  have  the  following  relation  to  one  another,  pro- 
ceeding from  without  inwards  :  (1)  Skin  ;  (2)  super- 
ficial fascia  ;  (3)  orbicularis  oris  ;  (4)  coronary  vessels  ; 
(5)  mucous  glands  ;  and  (6)  mucous  membrane.  The 
free  border  of  the  lip  is  very  sensitive,  many  of  the 
nerves  having  end  bulbs  closely  resembling  tactile  cor- 
puscles. The  upper  lip  is  supplied  with  sensation  by 
the  second  division  of  the  fifth  nerve,  and  the  lower 
lip  by  the  third  division.  Over  these  labial  nerves  a 
crop  of  herpes  often  appears  (herpes  labialis).  The 
free  border  of  the  lower  lip  is  more  frequently  the  seat 
of  epithelioma  than  is  any  other  part  of  the  body.  The 
lips  contain  a  good  deal  of  connective  tissue,  and  may 
swell  to  a  considerable  size  when  inflamed,  or  oede- 
matous.  They  are  very  mobile,  and  are  entirely  free 
for  a  considerable  extent  from  bony  attachment  of  any 
kind.  It  follows  that  destructive  inflammations  of  the 
lips,  and  such  losses  of  substance  as  accompany  severe 
burns,  produce  much  contraction  and  deformity  of  the 
mouth.  Contracting  cicatrices,  also,  in  the  vicinity  of 
the  mouth  are  apt  to  drag  upon  the  lips,  everting  them 
or  producing  kindred  distortions.  It  is  fortunate  that 
the  laxity  of  the  tissues  around  the  mouth,  and  the 
general  vascularity  of  the  part,  greatly  favour  the  success 
of  the  many  plastic  operations  performed  to  relieve 
these  deformities. 

The  lips  are  very  vascular,  and  are  often  the  seat 
of  noevi  and  other  vascular  tumours.  The  coronary 
arteries  are  of  large  size,  and  their  pulsations  can 
generally  be  felt  when  the  lip  is  pinched  up.  These 
vessels  run  beneath  the  orbicularis  oris  muscle,  and 
are  consequently  nearer  to  the  mucous  membrane  than 
they  are  to  the  skin.  When  the  inner  surface  of  the 
lip  is  cut  against  the  teeth,  as  the  result  of  a  blow,  these 


1 1 8  Surgical   Applied   Anatomy.  [Chap.vni. 

arteries  are  very  apt  to  be  wounded.  As  such  wounds 
are  concealed  from  view,  the  consequent  hsemorrhage 
has  sometimes  given  rise  to  an  erroneous  diagnosis. 
Thus,  Mr.  Erichsen  quotes  the  case  of  a  drunken  man, 
the  subject  of  such  a  wound,  who,  having  swallowed, 
and  then  vomited,  the  blood  escaping  from  a  coronary 
artery,  was  for  a  while  supposed  to  be  suffering  from  an 
internal  injury.  As  the  anastomoses  between  the 
arteries  of  the  lip  are  very  free,  it  is  usually  necessary 
to  tie  both  ends  of  the  vessel  when  it  has  been  cut  across. 

The  mucous  glands  in  the  submucous  tissue  are  large 
and  numerous.  From  closure  of  the  ducts  of  these 
glands,  and  their  subsequent  distension,  result  the 
"  mucous  cysts "  that  are  so  common  about  the  lips. 
It  has  been  shown  (Holmes'  "  System  of  Surgery," 
vol.  ii.)  that  one  form  of  enlarged  lip  may  depend  upon 
a  general  hypertrophy  of  these  glands  in  the  submucous 
tissue.  "  Hare-lip  "  is  noticed  below  in  connection  with 
the  subject  of  cleft  palate. 

The  buccal  cavity. — The  following  points  may 
be  noticed  in  the  examination  of  the  interior  of  the 
mouth.  On  the  floor  of  the  mouth,  and  on  either  side 
of  the  freenum  lingua?,  can  be  observed  the  sublingual 
papilla  with  the  openings  of  Wharton's  ducts.  The  duct 
of  Bartholin  (one  of  the  ducts  of  the  sublingual  gland) 
runs  along  the  last  part  of  Wharton's  duct,  and  opens 
either  with  it  or  very  near  it.  Wharton's  duct  is 
singularly  indistensible,  and  hence  is  partly  explained 
the  intense  pain  usually  observed  when  that  duct  is 
obstructed  by  a  calculus.  The  near  proximity  of  this 
duct  to  the  lingual  nerve  may  serve  also  to  account 
for  the  pain  in  some  cases.  The  submaxillary  gland 
can  be  made  out  through  the  mucous  membrane  at  a 
point  a  little  in  front  of  the  angle  of  the  jaw,  especially 
when  the  gland  is  pressed  up  from  the  outside  On  the 
floor  of  the  mouth,  between  the  alveolus  and  the  anterior 
part  of  the  tongue,  is  a  well-marked  ridge  of  mucous 
membrane,  that  is  directed  obliquely  forwards  and 
inwards  to  the  sublingual  papilla  near  the  frsenum. 
It  indicates  the  position  of  the  sublingual  gland,  and  also, 


Chap,  viii.]  The   Mouth.  119 

so  far  as  it  goes,  the  line  of  Wharton's  duct  and  the 
lingual  nerve.  These  structures,  with  the  sublingual 
artery,  lie  beneath  the  mucous  membrane  between 
the  gland  and  the  side  of  the  tongue.  The  ducts  of 
the  sublingual  gland,  some  ten  to  twenty  in  number, 
open  into  the  mouth  along  the  ridge  of  mucous  mem- 
brane just  referred  to.  Eanula,  a  cystic  tumour  filled 
with  mucous  contents,  is  often  met  with  over  the  site 
of  the  sublingual  gland,  and  is  due  to  the  dilatation  of 
one  of  the  gland  ducts  that  has  become  obstructed,  or 
to  an  occluded  mucous  follicle.  The  mucous  membrane 
of  the  floor  of  the  mouth,  as  it  passes  forward  to  be  re- 
flected on  the  gums,  is  attached  near  to  the  upper  border 
of  the  jaw.  Here  also  are  situated  some  mucous  glands 
which  may  become  cystic.  The  genio-hyo-glossus  is 
attached  near  the  lower  border.  Between  these  two 
parts  (the  mucous  membrane  and  the  muscle)  there  is, 
according  to  Tillaux,  a  small  space  lined  with  squamous 
epithelium.  To  this  cavity  the  name  is  given  of  the 
sublingual  bursa  mucosa.  It  is  constricted  in  its  centre 
by  the  fraenum  lingua?,  and  is  said  to  be  the  seat  of 
mischief  in  "  acute  ranula." 

When  the  mouth  is  widely  opened  the  pterygo- 
maxillary  ligament  can  be  readily  seen  and  felt  beneath 
the  mucous  membrane.  It  appears  as  a  prominent  fold 
running  obliquely  downwards  behind  the  last  molar 
teeth.  A  little  below  and  in  front  of  the  attachment  of 
this  ligament  to  the  lower  jaw,  the  gustatory  nerve  can 
be  felt  as  it  lies  close  to  the  bone  just  below  the  last  molar. 
This  nerve,  is  sometimes  divided  for  the  relief  of  pain 
in  cases  of  carcinoma  of  the  tongue.  Mr.  Moore's  method 
of  dividing  it  is  as  follows  :  "  He  cuts  the  nerve  about 
\  an  inch  from  the  last  molar  tooth,  at  a  point  where 
it  crosses  an  imaginary  line  drawn  from  that  tooth  to 
the  angle  of  the  jaw.  He  enters  the  point  of  the  knife 
nearly  £  of  an  inch  behind  and  below  the  tooth,  presses 
it  down  to  the  bone,  and  cuts  towards  the  tooth " 
(Stimson).  This  nerve,  as  it  lies  against  the  bone,  has 
been  crushed  by  the  slipping  of  the  forceps  in  the  clumsy 
extraction  of  the  lower  molar  teeth. 


1  2  O  Si' J!  GICA  L     A  PPL  [ED     A  NA  TOM  V.     [Chap.  V 1 1 1 . 

The  coronoid  process  of  the  lower  jaw  can  be  easily 
felt  through  the  mouth,  and  is  especially  distinct  when 
that  bone  is  dislocated.  It  may  be  noted  that  a  fair 
space  exists  between  the  last  molar  tooth  and  the  ramus 
of  the  inferior  maxilla,  through  which  a  patient  may  be 
fed  by  a  tube  in  cases  of  trismus  or  anchylosis  of 
the  jaw. 

A  congenital  dermoid  cyst  is  sometimes  found  in 
the  floor  of  the  mouth  between  the  tongue  and  the 
lower  jaw.  Such  cysts  have  been  supposed  to  be  due 
to  the  imperfect  closure  of  the  first  visceral  or  post- 
mandibular  cleft. 

The  gums  arc  dense,  firm,  and  very  vascular.  In 
the  bleeding  that  follows  the  extraction  of  teeth  much 
of  the  blood  is  supplied  by  them.  The  gums  are 
particularly  affected  in  mercurial  poisoning,  and  are 
also  especially  involved  in  scurvy.  In  chronic  lead- 
poisoning  a  blue  line  often  appears  along  their  margins. 
This  is  due  to  a  deposit  of  lead  sulphide  in  the  gum 
tissues,  which  is  thus  derived  :  Food  debris  collected 
about  the  teeth  in  decomposing  produces  hydrogen 
sulphide,  which,  acting  upon  the  lead  circulating  in  the 
blood,  produces  the  deposit.  The  blue  line,  therefore, 
is  said  not  to  occur  in  those  who  keep  the  teeth  clean. 

The  tongue. — On  the  under  surface  of  the  tongue, 
less  than  h  an  inch  from  the  fraenum,  the  end  of  the 
ranine  vein  can  be  seen  beneath  the  mucous  membrane. 
Two  elevated  and  fringed  lines  of  mucous  membrane 
may  be  seen  on  the  under  surface  of  the  organ 
converging  towards  its  tip.  They  indicate  the  position 
of  the  ranine  artery,  which  is  more  deeply  placed  than 
the  vein,  close  to  which  it  lies.  It  is  extremely  rare 
for  the  tongue  to  be  the  seat  of  congenital  defect.  The 
author  of  the  able  monograph  on  the  tongue  in  Holmes' 
"  System  of  Surgery  "  has  discovered  only  one  instance 
of  congenital  absence  of  the  organ.  Fournier  gives  a 
case  where  the  tongue  was  so  much  longer  than  usual 
that  the  chest  could  be  touched  with  its  tip  while  the 
head  was  held  erect. 

In    rare   cases    the    frseiiiim    linguae    may    be 


chap,  viii.]  The    Tongue,  121 

abnormally  short,  constituting  the  condition  known  as 
"  tongue-tie,"  which  is  really  a  very  uncommon  affection. 
The  frsenum  when  divided  should  be  cut  as  near  the  jaw 
as  possible,  so  as  to  avoid  the  ranine  vessels.  Division 
of  these  vessels  in  relieving  tongue-tie  has  led  to  fatal 
hemorrhage,  the  bleeding  being  encouraged  by  the 
efforts  of  sucking.  "If  the  frsenum  and  subjacent 
muscle  fibres  be  too  freely  divided,  energetic  sucking 
on  the  part  of  a  hungry  child  may  tear  the  wound  of 
these  very  lax  tissues  farther  and  farther  open,  until 
the  tongue,  having  lost  all  its  anterior  support,  turns 
over  into  the  pharynx,  and  is  firmly  embraced  by  the 
muscles  of  deglutition,  which  force  it  down  upon  the 
epiglottis,  and  the  latter  upon  the  larynx,  until  suffoca- 
tion is  produced "  (Holmes'  "  System  of  Surgery," 
vol.  ii.).  In  complete  anaesthesia,  as  in  that  produced 
by  chloroform,  when  all  the  muscular  attachments  of 
the  tongue  are  relaxed,  the  organ  is  apt  to  fall  back 
and  to  press  down  the  epiglottis,  so  causing  suffocation, 

The  tongue  is  firm  and  dense,  but  contains,  never- 
theless, a  sufficient  amount  of  connective  tissue  to  cause 
it  to  swell  greatly  when  inflamed.  Foreign  bodies  may 
easily  be  embedded  in  its  substance.  In  the  Lancet  for 
184G  is  noted  a  case  where  a  portion  of  a  fork  is  said  to 
have  been  buried  in  the  tongue  for  thirty-two  years. 
The  surface  epithelium  is  thick,  and  in  chronic  super- 
ficial inflammation  of  the  organ  it  often  becomes  heaped 
up,  forming  dense  opaque  layers,  ichthyosis  linguae, 
plaques  cles  fumeurs,  leucoma,  etc.  From  the  mucous 
glands,  situated  chiefly  beneath  the  mucous  membrane 
near  the  base  of  the  tongue,  the  mucous  cysts  are  de- 
veloped that  are  sometimes  met  with  in  this  part. 

The  tongue  is  very  vascular,  and  is  in  consequence 
often  the  seat  of  nevoid  growths.  Its  main  supply  is 
from  the  lingual  artery.  This  vessel  approaches  the 
organ  from  the  under  surface,  and  as  cancer  usually 
shows  a  tendency  to  spread  towards  the  best  blood  supply, 
it  is  to  be  noticed  that  carcinoma  of  the  tongue  nearly 
always  tends  to  spread  towards  the  deep  attachment 
of  the  member.     At  the  same  time  it  must  be  observed 


122  Surgical   Applied   Anatomy.   [Chap.  viii. 

that  the  main  lymphatics  follow  the  same  course  as  the 
main  blood-vessels.  The  vascularity  of  the  tongue  is 
the  great  bar  to  its  easy  removal,  haemorrhage  being 
the  complication  most  to  be  dreaded  in  such  operations. 
The  tongue  is  well  supplied  with  nerves,  that  endue 
it  not  only  with  the  special  sense  of  taste,  but  also  with 
common  sensation.  According  to  Weber's  experiments, 
tactile  sensibility  is  more  acute  on  the  tip  of  the  tongue 
than  it  is  on  any  other  part  of  the  surface  of  the  body. 
It  should  be  borne  in  mind  that  the  lingual  nerve  supplies 
the  forepart  and  sides  of  the  tongue  for  two-thirds  of 
its  surface,  while  the  glossopharyngeal  nerve  supplies 
the  mucous  membrane  at  its  base,  and  especially  the 
papillae  vallatae.  In  painful  affections  of  the  tongue 
in  the  district  supplied  by  the  lingual  nerve,  the  patient 
often  is  troubled  with  severe  pain  deep  in  the  region 
of  the  meatus  of  the  ear,  and  an  area  of  skin  from  the 
ear  along  the  lower  border  of  the  jaw  may  be  tender 
(Head).  The  anterior  two-thirds  of  the  tongue  is  a 
derivative  of  the  mandibular  arch,  which  also  forms  the 
anterior  boundary  of  the  meatus.  Hence  the  nerve 
supply  of  the  anterior  part  of  the  tongue  from  the  third 
division  of  the  fifth  nerve  and  the  reference  of  pain  to  its 
cutaneous  termination.  The  posterior  third  of  the  tongue 
is  derived  from  the  second  (hyoid)  and  third  visceral 
arches  and  is  associated  with  tender  areas  in  the  skin 
over  the  larynx  (Head).  Spasmodic  contraction  of  the 
masticatory  muscles  is  sometimes  found  to  accompany 
painful  lingual  ulcers  when  involving  the  region  of  the 
gustatory  nerve.  There  would  seem  to  be  but  little 
connection  between  an  abscess  over  the  occipital  region 
and  wasting  of  one  half  of  the  tongue.  But  Sir  James 
Paget  reports  the  following  case  :  "  A  man  received 
an  injury  to  the  back  of  his  head  that  was  apparently 
not  severe.  In  time  the  right  half  of  the  tongue  began 
to  waste,  and  continued  to  waste  until  it  was  less  than 
half  the  size  of  the  unaltered  side.  An  abscess  formed 
over  the  occiput,  from  which  fragments  of  the  lower 
part  of  the  occipital  bone  were  removed.  After  the 
removal  of  all  the  dead  bone  the  tongue  began  to  recover, 


Ch aP.  v  1 1 1 .  ]  The    Toxg  i  te.  123 

and  in  one  month  had  nearly  regained  its  normal  aspect." 
Here  the  atrophy  was  due  to  wasting  of  the  lingual 
muscles  produced  by  pressure  upon  the  hypoglossal 
nerve,  which  leaves  the  skull  through  the  anterior 
condyloid  foramen  in  the  occipital  bone.  The  case 
illustrates  the  importance  of  remembering  even  small 
foramina,  and  the  structures  they  transmit. 

The  tongue  contains  much  lymphoid  tissue,  a  con- 
siderable part  of  which  (the  lingual  tonsil)  is  massed 
under  the  mucous  membrane  at  the  posterior  part  of 
the  organ.  Hypertrophy  of  this  tissue  may  lead  to 
troublesome  symptoms  by  interference  with  the  proper 
action  of  the  epiglottis.  The  lingual  and  pharyngeal 
adenoid  tissue,  with  the  tonsils  proper,  form  a  complete 
ring  of  lymphoid  tissue  round  the  isthmus  of  the  fauces. 

The  lymphatics  of  the  tongue  are  large  and  numerous, 
and  offer  a  free  channel  for  the  dissemination  of  cancerous 
emboli.  The  tongue  is  one  of  the  commonest  sites  for 
cancer,  and  the  disease  commonly  affects  the  anterior 
two-thirds,  which  is  derived  from  the  mandibular  arch. 
So  is  the  lower  lip,  which  also  is  a  common  site.  Cancer 
spreads  along  the  lymphatic  vessels,  which  for  the  greater 
part  accompany  the  lingual  vein  and  artery  and  pour  their 
lymph  and  emboli  in  the  upper  deep  cervical  glands, 
behind  and  below  the  angle  of  the  jaw.  The  normal 
paths  are  soon  choked,  and  the  lymph  has  to  follow 
circuitous  by-paths.  The  lymphatic  glands  over  the 
submaxillary  gland,  the  lymphoid  tissue  in  that  gland 
and  in  the  sublingual,  become  the  seats  of  secondary 
deposit.     The  submental  gland  may  also  be  affected. 

In  the  strange  congenital  affection  known  as  macro- 
glossia  the  tongue  becomes  much  enlarged,  and  in  some 
cases  may  attain  prodigious  dimensions.  Thus,  in  one 
case  it  measured  Q\  inches  in  length  and  10  inches 
in  circumference.  It  has  protruded  so  far  from  the 
mouth  as  to  reach  even  to  the  episternal  notch.  It 
has  been  so  large  as  to  deform  the  teeth  and  alveolus, 
and  in  one  case  dislocated  the  jaw.  The  enlargement 
is  primarily  due  to  the  greatly  dilated  condition  of  the 
Lymphatic    channels   of   the   organ   (hence   the    name, 


124  Surgical   Applied   Anatomy.  [Chap.  vni. 

lymphangioma,  cavernosum,  proposed  by  Vircliow), 
and  to  an  increased  development  of  lymph  tissue  through- 
out the  part.  The  portion  most  conspicuously  affected 
is  the  base  of  the  tongue,  where  the  lymphatics  are 
usually  the  most  numerous. 

A  dermoid  cyst  may  be  met  with  on  the  under  surface 
of  the  tongue.  It  is  usually  placed  in  the  median  line 
between  the  genio-hyo-glossi  muscles.  Such  cysts  are 
probably  due  to  some  infolding  of  the  integumental 
layer  during  development. 

Accessory  glands  about  the  tongue.— 
Streckeisen  states  that  accessory  glands,  belonging  to 
the  thyroid  body,  are  frequently  found  in  the  vicinity 
of  the  hyoid  bone.  Some  may  be  superficial  to  the 
mylo-hyoid  muscle,  others  may  be  just  above  the  hyoid 
bone,  and  others  in  the  hollow  of  that  bone.  Cysts 
lined  with  ciliated  epithelium  may  sometimes  be  found 
in  the  same  situations.  All  these  structures  are  the 
remains  of  the  neck  of  the  central  diverticulum  which 
is  protruded  from  the  ventral  wall  of  the  pharynx  in 
the  embryo,  and  from  which  the  isthmus  and  pyramidal 
parts  of  the  thyroid  gland  are  formed.  The  foramen 
caecum  on  the  tongue  indicates  the  spot  where  this 
diverticulum  leaves  the  pharynx.  It  marks  the  junction 
of  the  mandibular  with  the  hyoid  part  of  the  tongue. 
Ducts  lined  with  epithelium  have  been  found  leading 
from  the  foramen  caecum  to  accessory  glands  about 
the  hyoid  bone.  It  is  probably  from  these  glandular 
and  epithelial  collections  about  the  hyoid  bone  that 
certain  deep-seated  forms  of  cancer  of  the  neck  are 
developed.  Some  of  these  take  the  form  of  malignant 
cysts  described  by  the  author  {Path.  Soc.  Trans.,  1886). 

Excision. — Many  different  methods  have  been 
adopted  for  the  removal  of  the  entire  tongue.  It  has 
been  removed  through  the  mouth  by  the  ecraseur  or 
the  scissors,  the  latter  operation  being  performed  with 
or  without  previous  ligature  of  the  lingual  arteries  in 
the  neck.  It  is  difficult,  however,  to  fully  expose  the 
deeper  attachments  of  the  organ  through  the  com- 
paratively small  orifice  of  the  mouth.     To  pbtain  more 


chap,  viii.i  The    Tongue.  125 

room  the  cheek  lias  been  slit  up  in  one  procedure,  while 
the  lower  lip  and  symphysis  of  the  lower  jaw  have  been 
divided  in  another. 

In  another  series  of  operations  the  tongue  has  been 
reached",  or  the  organ  has  been  fully  exposed,  by  an 
incision  made  between  the  hyoid  bone  and  the  inferior 
maxilla.  More  recently  Kocher  has  exposed  the  tongue 
from  the  neck,  and  has  reached  it  by  an  incision  com- 
mencing near  the  ear  and  following  the  anterior  border 
of  the  sterno-mastoid  muscle  as  far  as  the  hyoid  bone, 
whence  it  turns  upwards  along  the  anterior  belly  of 
the  digastric  muscle.  This  method  allows  free  removal 
of  the  upper  deep  cervical  glands,  the  lymphatic  glands, 
and  tissue  over  and  in  the  submaxillary  and  sublingual 
glands  which  form  the  seat  of  secondary  cancerous 
deposits.  * 

In  the  removal  of  the  entire  organ,  the  following 
parts  are  of  necessity  divided  :  The  fnenum,  the  mucous 
membrane  along  the  sides  of  the  tongue,  the  glasso- 
epiglottic  folds,  the  genio-hyo-glossus,  hyo-glossus, 
stylo-glossus,  palato-glossus  muscles,  the  few  fibres 
of  the  superior  and  inferior  linguales  muscles  that  are 
attached  to  the  hyoid  bone,  the  terminal  branches 
of  the  gustatory,  glossopharyngeal,  and  hypo-glossal 
nerves,  the  lingual  vessels,  and,  at  the  side  of  the  tongue 
near  its  base,  some  branches  of  the  ascending  pharyngeal 
artery,  and  of  the  tonsilar  branch  of  the  facial  artery. 

Bleeding  from  the  stump  of  the  tongue,  after  removal, 
can  be  instantly  and  almost  entirely  arrested  by  pressing 
the  root  of  the  tongue  forwards  with  two  fingers  passed 
down  behind  it  into  the  pharynx.  The  lingual  arteries 
as  they  lie  divided  in  the  floor  of  the  mouth  are  difficult 
to  secure.  They  are  embedded  in  muscle,  and  appear 
to  be  peculiarly  brittle. 

When  both  Unguals  have  been  ligatured  in  the 
neck  (through  the  hyo-glossus  muscle)  before  removing 
the  tongue,  bleeding  still  takes  place  from  the  dorsalis 
linguae  branches  of  the  lingual  and  from  small  branches 
of  the  ascending  pharyngeal  and  facial  arteries. 

The  palate.— The  arch  of   the  hard  palate  varies 


126  Surgical   Applied   Anatomy.   [Chap,  viii 

in  height  and  shape  in  different  individuals,  and  it 
has  been  said  that  the  arch  is  particularly  narrow  and 
high  in  congenital  idiots.  The  outline  of  this  arch 
is  of  some  moment  in  operations  upon  the  palate. 

Cleft  palate. — The  palate  is  often  the  seat  of  a 
congenital  cleft.  The  cleft  is  precisely  in  the  middle 
line.  It  may  involve  the  uvula  or  the  soft  palate  alone, 
or  may  extend  forwards  and  involve  the  hard  palate 
as  far  as  the  alveolus.  If  it  extend  beyond  the  alveolus, 
the  cleft  will  leave  the  middle  line  and  will  follow  the 
suture  between  the  superior  maxillary  bone  and  the 
os  incisivum,  appearing  therefore  between  the  incisor 
and  canine  teeth.  The  os  incisivum  or  premaxillary 
bone  is  developed  with  the  central  part  of  the  upper 
lip  from  the  fronto-nasal  process  (Fig.  17,  p.  98).  Each 
premaxillary  may  be  developed  by  two  centres,  hence 
the  cleft  is  sometimes  between  the  central  and  lateral 
incisor.  Sometimes  at  the  end  of  the  cleft  the  upper 
lip  is  fissured  (hare-lip).  Hare-lip  is  exceedingly  rare 
in  the  middle  line.  The  slit  usually  corresponds  to  the 
suture  j  List  named,  and  is  therefore  opposite  the  interval 
between  the  lateral  incisor  and  canine  teeth.  Sometimes 
the  cleft  in  the  palate  on  reaching  the  alveolus  will  run 
on  either  side  of  the  os  incisivum,  so  that  that  bone 
is  entirely  separated  from  the  superior  maxilla.  Such 
cases  are  associated  with  double  hare-lip,  and  the  os 
incisivum  appears  as  a  nodule  attached  to  the  nose 
and  suspended  in  the  centre  of  the  gap.  The  bone 
in  these  cases  contains,  as  a  rule,  the  germs  only  of  the 
central  incisors,  the  lateral  incisors  having  been  lost 
in  the  cleft.  Hare-lip  very  commonly  exists  without 
any  cleft  of  the  palate.  Except  in  very  rare  instances, 
a  cleft  of  the  hard  palate  will  not  exist  without  a  cleft 
of  the  soft.  In  some  cases  the  os  incisivum  may  be 
entirely  absent,  and  then  the  double  hare-lip  that  exists 
may  appear  as  a  large  median  gap  in  the  lip.  When 
the  hard  palate  is  entirely  cleft  the  edges  of  the  cleft 
are  more  or  less  perpendicular,  whereas  when  the  cleft 
is  very  slight  as  regards  its  antero-posterior  length,  the 
palate  tends  to  preserve  more  or  less  of  its  normal  curve. 


Chap,  v  1 1 1 .  ]  The  Pa  la  te.  i  2  7 

The  buccal  cavity,  when  first  formed  in  the  foetus, 
exists  as  a  wide  cleft  in  the  face  bounded  above  by  the 
fronto-nasal  process,  at  the  sides  by  the  superior  maxillary 
processes,  and  below  by  the  first  visceral  arch,  from 
which  the  lower  jaw  is  formed  (Fig.  17,  p.  (J8).  The  nasal 
and  buccal  cavities  are  one.  "  The  separation  of  the 
cavity  of  the  mouth,  strictly  so  called,  from  the  nasal 
fossae,  is  effected  by  the  development  of  the  palatal 
or  pterygo-palatal  processes  of  the  maxillary  plate, 
which,  advancing  inwards  from  the  two  sides,  meet 
and  coalesce  with  each  other  and  with  the  septum 
descending  from  above  in  the  middle  line.  .  .  .  When 
the  union  of  the  opposite  parts  takes  place,  the  naso- 
palatine canal  is  left  as  the  vestige  of  the  previous  fissures. 
The  median  union  of  the  palate  begins  in  front  about 
the  eighth  week  in  the  human  embryo,  and  readies 
the  back  part,  when  completed,  in  the  ninth  and  tenth 
weeks  "  (Allen  Thomson,  in  Quain's  "  Anatomy  "). 

In  this  way  the  hard  and  soft  palates  are  formed, 
and  the  upper  lip  completed  ;  and  it  will  be  understood 
that  hare-Hp  and  cleft  palate  depend  simply  upon 
imperfect  closure  of  the  foetal  gap  between  the  nasal 
and  buccal  cavities. 

The  mucous  membrane  covering  the  hard 
palate  is  peculiar  in  that  it  is  practically  one  with 
the  periosteum  covering  the  bones  ;  and,  therefore,  in 
dissecting  up  this  membrane  the  bone  is  bared,  as  the 
mucous  membrane  and  the  periosteum  cannot  be 
separated.  The  membrane  is  thin  in  the  middle  line, 
but  is  much  thicker  at  the  sides  near  the  alveoli,  the 
increased  thickness  depending  mainly  upon  the  intro- 
duction of  a  number  of  mucous  glands  beneath  the 
.surface  layers,  such  glands  being  absent  in  the  middle 
line.  The  density  and  toughness  of  the  soft  covering 
of  the  hard  palate  render  it  very  easy  to  manipulate 
when  dissected  up  in  the  form  of  flaps  in  the  operation 
for  the  cleft  palate. 

The  main  blood  supply  of  both  the  bones  of  the 
hard  palate  and  its  mucous  covering  is  derived  from 
the  descending  palatine  brunch  of  the  internal  maxillary 


128  Surgical   Applied   Anatomy.  [Chap.  Viii. 

artery.  This  vessel,  which  is  practically  the  only  vessel 
of  the  hard  palate,  emerges  from  the  posterior  palatine 
canal  near  the  junction  of  the  hard  palate  with  the 
soft,  and  close  to  the  inner  side  of  the  last  molar  tooth. 
The  vessel  runs  forwards  and  inwards,  to  end  at  the 
anterior  palatine  canal.  Its  pulsations  on  the  palate 
can  often  be  distinctly  felt.  In  dissecting  up  muco- 
periosteal  flaps  from  the  hard  palate,  it  is  most  important 
to  make  the  incision  in  the  mucous  membrane  close 
to,  and  parallel  with,  the  alveolus,  so  that  this  artery 
may  be  included  in  the  flap  and  its  vitality  therefore 
not  be  endangered.  By  such  an  incision,  also, 
unnecessary  bleeding  is  avoided.  In  dissecting  up  the 
flap  it  should  be  remembered  that  the  artery  runs  much 
nearer  to  the  bone  than  to  the  mucous  surface. 

The  soft  palate  is  of  uniform  thickness,  its 
average  measurement  being  estimated  at  about  \ 
of  an  inch.  When  the  soft  palate  is  cleft,  the  edges 
of  the  fissure  are  approximated  during  swallowing  by 
the  uppermost  fibres  of  the  superior  constrictor.  This 
approximation  may  narrow  the  cleft  to  one-third  or 
one-half  of  its  previous  size.  The  muscles  that  tend 
to  widen  the  cleft  are,  in  the  main,  the  levator  palati 
and  tensor  palati.  It  is  necessary  that  these  muscles 
should  be  divided  before  attempting  to  close  the  cleft 
by  operation.  The  levator  palati  crosses  the  palate 
obliquely  from  above  downwards  and  inwards  on  its 
way  to  the  middle  line,  lying  nearer  to  the  posterior 
than  the  anterior  surface  of  the  velum.  The  tensor 
palati  turns  round  the  hamular  process,  and  passes  to 
the  middle  line  in  a  nearly  horizontal  direction.  The 
hamular  process  can  be  felt  through  the  soft  palate 
just  behind  and  to  the  inner  side  of  the  last  upper  molar 
tooth.  There  are  three  principal  methods  of  dividing 
these  muscles  :  (1)  Ferguson's  :  A  small  knife,  with 
the  blade  at  right  angles  to  the  stem,  is  passed  through 
the  cleft,  and  is  made  to  divide  the  levator  palati  by 
an  incision  on  the  posterior  aspect  of  the  palate,  trans- 
verse to  the  direction  of  the  muscle.  The  tensor  is  not 
divided  in  this  procedure.     (2)  Pollock's  :  A  thin  narrow 


Chap.  VII  f.] 


The    Palate. 


129 


knife,  with  the  cutting  edge  upwards,  is  introduced 
into  the  soft  palate  a  little  in  front,  and  to  the  inner  side 
of  the  hamular  process.  The  tendon  of  the  tensor  muscle 
is  above  the  knife,  and  is  cut  as  the  knife  is  pushed 
upwards  and  inwards.  The  knife  is  inserted  until 
its  point  presents  at  the  upper  part  of  the  cleft.  As 
it  is  being  withdrawn,  it  is  made  to  cut  the  posterior 
surface  of  the  velum  to  a  sufficient 
depth  to  divide  the  levator  palati 
(Fig.  19).  (3)  Bryant's  :  Here 
the  palate  muscles  are  divided  by 
a  cut  with  the  scissors  that  involves 
the  entire  thickness  of  the  velum, 
the  cut  being  at  the  side  of  the 
velum,  and  nearly  parallel  with 
the  cleft. 

The  blood  supply  of  the  soft 
palate  is  derived  from  the  descend- 
ing palatine  branch  of  the  in- 
ternal maxillary  artery,  the  as- 
cending pharyngeal  artery,  and 
the  ascending  palatine  branch 
of  the  facial  artery.  The  latter 
vessel  reaches  the  velum  by  fol- 
loAving  the  levator  palati  muscle, 
and  must  be  divided  in  the  section 
made  of  this  muscle  in  the 
procedures  just  described. 

The  muscles  of  the  palate  are  supplied  by  several 
nerves.  The  levator  palati,  azygos  uvulae,  and  palato- 
pharyngeus  are  innervated  with  the  muscles  of  the 
pharynx  by  the  spinal  accessory  ;  the  palatoglossus 
with  the  muscles  of  the  tongue  from  the  hypo- 
glossal, and  the  tensor  palati  with  the  tensor  tympani 
from  the  third  division  of  the  fifth  nerve  through  the 
otic  ganglion. 

The  pharynx  is  about  five  inches  in  length.  It 
is  much  wider  from  side  to  side  than  from  before  back- 
wards. It  is  widest  at  the  level  of  the  tip  of  the  greater 
cornua  of   the  hyoid  bone,  where  it  measures   about 


e  f 

Fig.  19.— The  Muscles  of 
the  Soft  Palate,  from 
behind. 

a.  Levator  palati  ;  b,  tensor 
palati ;  c,  hamular  process; 
d,  wall  of  pliHiynx;  e.  azy- 
gos uvula? ;  /,  the  point  of 
entry  of  the  knife  in  Pol- 
lock's operation;  above  it 
is  the  line  of  incision  made 
on  withdrawing  the  knife. 


130  Surgical   Applied  Anatomy.  [Chap.  viii. 

2  inches.  It  is  narrowest  where  it  joins  the  gullet  oppo- 
site the  cricoid  cartilage,  its  diameter  here  being  less 
than  f  of  an  inch.  The  pharynx  is  not  so  large  a  space 
as  supposed,  for  it  must  be  remembered  that  during 
life  it  is  viewed  very  obliquely,  and  erroneous  notions 
are  thus  formed  of  its  antero-posterior  dimensions. 
The  distance  from  the  arch  of  the  teeth  to  the  commence- 
ment of  the  gullet  is  about  6  inches,  a  measurement 
that  should  be  borne  in  mind  in  extracting  foreign 
bodies.  Foreign  bodies  passed  into  the  pharynx  are 
most  apt  to  lodge  at  the  level  of  the  cricoid  cartilage, 
a  point  that,  in  the  adult,  is  a  little  beyond  the  reach  of 
the  finger.  The  history  of  foreign  bodies  in  the  pharynx 
shows  that  that  cavity  is  very  dilatable,  and  can  accom- 
modate for  some  time  large  substances.  Thus,  in  a  case 
reported  by  Dr.  Geoghegan,  a  man  of  60,  who  had 
for  months  some  trouble  in  his  throat  for  which  he  could 
not  account,  was  supposed  to  have  cancer.  On  examina- 
tion, however,  a  plate  carrying  five  false  teeth,  and 
presenting  niches  for  five  natural  ones,  was  found  em- 
bedded in  the  pharynx,  where  it  had  been  lodged  for 
five  months.  The  plate  had  been  swallowed  during 
sleep  {Med.  Press,  1866).  In  the  Lancet  for  1868  is  an 
account  of  a  mutton  chop  that  became  lodged  in  the 
pharynx  of  a  gluttonous  individual.  The  chop  pre- 
sented the  ordinary  vertebral  segment  of  bone,  together 
with  1|-  inches  of  ribs,  and  was  "  pretty  well  covered  with 
meat."  Attempts  to  remove  it  failed,  and  it  was  finally 
vomited  up.  Dr.  Hicks  (Lancet,  1884)  reports  the  case 
of  a  woman  who  committed  suicide  by  cramming  half 
a  square  yard  of  coarse  calico  (belonging  to  her 
nightdress)  into  her  mouth  and  throat. 

The  walls  of  the  pharynx  are  in  relation  with  the 
base  of  the  skull,  and  with  the  upper  six  cervical  ver- 
tebrae. The  arch  of  the  atlas  is  almost  exactly  on  a 
line  with  the  hard  palate.  The  axis  is  on  a  line  with 
the  free  edge  of  the  upper  teeth.  The  termination 
of  the  pharynx  corresponds  to  the  sixth  cervical  ver- 
tebra. The  upper  vertebrae  can  be  examined,  as  regards 
their   anterior   surface,   from   the   mouth.    When   the 


Chap,  vin.]  The  Pharynx.  131 

bones  about  the  pharynx  are  diseased,  the  necrosed 
parts  may  be  discharged  by  that  cavity.  Thus  por 
tions  of  the  atlas  and  axis  have  been  expelled  by  the 
mouth,  as  also  have  been  some  fragments  of  compara- 
tively large  size  thrown  off  by  the  occipital  and  sphenoid 
bones. 

The  mucous  membrane  of  the  pharynx  is  vascular, 
and  readily  inflamed ;  and  such  inflammations  are 
peculiarly  dangerous,  in  that  they  may  spread  to  the 
lining  membrane  of  the  larynx.  The  submucous  tissue 
of  the  aryteno-epiglottic  folds  and  of  the  neighbouring 
part  of  the  pharynx  is  peculiarly  loose,  and  in  cedema- 
tous  conditions  the  upper  aperture  of  the  larynx  may 
be  almost  closed.  Much  adenoid  tissue  is  distributed 
in  the  mucous  membrane  of  the  pharynx,  and  it  is  this 
tissue  that  is  the  primary  seat  of  inflammation  in  scrofu- 
lous pharyngitis.  A  distinct  collection  of  adenoid  tissue 
stretches  across  the  hinder  wall  of  the  pharynx  between 
the  openings  of  the  Eustachian  tubes.  It  is  known  as 
Luschkas  tonsil,  or  the  pharyngeal  tonsil.  This  deposit 
of  adenoid  tissue  may  undergo  hypertrophic  change 
and  the  condition  known  as  "  adenoid  vegetations " 
or  "  post-nasal  growths  "  be  produced.  These  growths 
may  cause  deafness,  and  may  block  the  posterior  nares. 
They  need  to  be  removed  by  operation.  The  lateral 
recess,  behind  the  opening  of  the  Eustachian  tube,  also 
contains  adenoid  tissue  (Fig.  16,  p.  89).  The  tissue  immedi- 
ately outside  the  pharynx  walls  is  lax,  and  favours  the 
spread  of  effusion.  Thus,  in  acute  inflammation  of  the 
pharynx  the  effusion  has  been  found  to  extend  along 
the  ccsophagus,  reaching  the  posterior  mediastinum 
and  advancing  even  to  the  diaphragm.  In  the  lax 
connective  tissue  betAveen  the  pharynx  and  the  spine 
abscess  is  not  infrequent,  due,  as  a  rule,  to  caries  of 
the  vertebrae  (post-pharyngeal  abscess).  In  this  con- 
nective tissue,  and  opposite  the  axis,  is  also  found  a 
lymphatic  gland  that  receives  lymphatics  from  the 
nares.  This  gland  may  prove  the  seat  of  a  suppura- 
tion. Such  collections  may  so  push  forward  the  pos- 
terior pharyngeal  wall  as  to  depress  the  soft  palate, 


132  Surgical   Applied   Anatomy.   fChap. vni. 

or  may  cause  severe  dyspnoea  by  interference  with  tlie 
larynx.  The  matter  may  discharge  itself  through  the 
mouth,  or  may  reach  the  neck  by  passing  behind  the 
great  vessels  and  the  parotid  gland,  presenting  ulti- 
mately beneath  or  at  one  border  of  the  sterno-mastoid 
muscle. 

Many  structures  of  importance  are  in  relation  with 
the  lateral  walls  of  the  pharynx,  the  principal  being  the 
internal  carotid  artery,  the  vagus,  glossopharyngeal, 
and  hypoglossal  nerves.  The  internal  carotid  is  so 
close  to  the  pharynx  that  its  pulsations  may  be  felt 
by  the  finger  introduced  through  the  mouth.  These, 
and  other  deep  structures  in  the  neck,  may  be  wounded 
by  foreign  bodies,  that,  passing  in  at  the  mouth,  have 
been  thrust  through  the  pharynx  into  the  cervical 
tissues.  The  internal  jugular  vein  is  at  some  distance 
from  the  pharynx,  especially  at  its  upper  part  (Fig. 
18,  p.  104).  The  styloid  process,  when  prominent,  and  an 
ossified  stylo-hyoid  ligament,  can  also  be  felt  at  the  side 
of  the  pharynx.  In  more  than  one  case  an  ossified 
stylo-hyoid  ligament  has  been  mistaken  for  a  foreign 
body,  and  an  attempt  made  to  excise  it.  Langenbeck 
has  three  times  extirpated  the  pharynx  for  malignant 
disease,  but  without  success.  He  reaches  it  from  the 
neck  through  an  incision  that,  beginning  below  the  jaw, 
midway  between  the  symphysis  and  angle,  is  carried  over 
the  great  cornu  of  the  hyoid  bone,  and  ends  close  to  the 
cricoid  cartilage.  The  posterior  belly  of  the  digastric 
and  the  stylo-hyoid  muscles  are  detached  from  the  hyoid 
bone,  while  the  omo-hyoid  muscle,  the  lingual,  facial, 
and  superior  thyroid  arteries,  and  the  superior  laryngeal 
nerve  are  divided. 

The  tonsil  is  lodged  between  the  anterior  and 
posterior  palatine  arches.  It  is  in  relation  externally 
with  the  superior  constrictor  muscle,  and  corresponds, 
as  regards  the  surface,  to  the  angle  of  the  lower  jaw. 
It  is  questionable  whether  the  enlarged  tonsil,  when 
it  is  the  subject  of  other  than  malignant  enlargement, 
can  ever  be  felt  externally.  When  hypertrophied,  the 
mass  tends  to  develop  towards  the  middle  line,  where 


Ch  ap.  v  1 1  i .  ]  The    Tonsil  .  133 

no  resistance  is  encountered,  and  to  effect  but  little 
change  in  its  external  relations.  The  mass,  often  mis- 
taken for  the  enlarged  tonsil  in  the  neck,  is  formed  of 
enlarged  glands,  situate  near  the  tip  of  the  great  cornu 
of  the  hyoid  bone,  and  overlying  the  internal  jugular 
vein.  These  glands  receive  the  tonsillar  lymphatics, 
and  are  almost  invariably  enlarged  in  all  tonsil  affections. 
The  fact  that  these  glands  are  so  frequently  the  first  to 
enlarge  when  the  cervical  glands  become  tubercular 
points  to  the  tonsil  as  a  common  site  of  primary  infection. 
It  must  be  remembered  that  many  structures  are  inter- 
posed between  the  tonsil  and  the  skin,  and  as  the  hyper- 
trophied  body  projects  freely  into  the  pharyngeal  cavity, 
one  would  not  expect  that  it  could  be  readily  felt,  even 
were  the  interposed  tissues  less  extensive  than  they  are. 
The  tonsil  is  closely  enough  attached  to  the  pharyngeal 
wall  to  be  affected  by  the  movements  of  the  pharyngeal 
muscles.  Thus  it  is  moved  inwards  by  the  superior  con 
strict  or  muscle  during  the  act  of  swallowing,  and  may 
be  drawn  outwards,  on  the  other  hand,  by  the  stylo- 
pharyngeus  muscle.  The  ease  with  which  a  tonsil  can 
be  reached  depends,  other  things  being  equal,  upon 
the  extent  to  which  it  can  be  withdrawn  by  the  stylo- 
pharyngeus,  and  upon  the  development  of  the  anterior 
palatine  arch,  which,  to  some  extent,  hides  the  tonsil. 
A  child  with  a  prominent  anterior  palatine  arch,  con- 
taining a  well-developed  palato-giossus  muscle,  and  with 
a  vigorous  stylo-pharyngeus,  can  for  a  long  time  elude 
the  tonsil  guillotine. 

Deafness  is  often  complained  of  when  the  tonsil  is 
hypertrophied.  This  is  not  due  to  closure  of  the 
Eustachian  tube  by  the  direct  pressure  of  the  enlarged 
mass.  Such  pressure  is  anatomically  impossible,  The 
large  tonsil  may,  however,  affect  the  patency  of  the 
tube,  by  disturbing  the  soft  palate,  and  through  it  the 
tensor  palati  muscle,  which  is  much  concerned  in  keep- 
ing open  the  Eustachian  tube.  The  deafness  in  these 
cases  is  probably  due  rather  to  an  extension  of  the 
hypertrophic  process  to  the  lining  membrane  of  the 
tube  than  to  any  pressure  effects,  since  it  is  usually 


T34  Surgical   Applied   Anatomy,   [Chap,  viii; 

not  improved  until  some  time  after  the  tonsil  has  been 
removed.  The  tonsil  tissue  is  for  the  most  part  collected 
around  a  number  of  recesses.  The  decomposition  of 
retained  epithelial  structures  within  those  recesses 
produces  the  foetid  breath  often  noticed  in  cases  of 
enlarged  tonsil,  and  probably  incites  the  attacks  of 
inflammation  to  which  such  tonsils  are  liable.  Calculi 
may  form  in  these  crypts  and  give  rise  to  a  spas- 
modic cough.  In  this  case  the  glosso  -  pharyngeal 
nerve  conveys  the  afferent  impulse  to  the  respiratory 
centre. 

The  tonsil  is  very  vascular,  receiving  blood  from  the 
tonsillar  and  palatine  branches  of  the  facial  artery, 
from  the  descending  palatine  branch  of  the  internal 
maxillary,  from  the  dorsalis  linguse  of  the  lingual,  and 
from  the  ascending  pharyngeal.  Hence  the  operation 
of  removing  the  tonsil  is  often  associated  with  free 
bleeding.  The  internal  carotid  artery  is  close  to  the 
pharynx,  but  some  way  behind  the  gland  (Fig.  18,  p.  104). 
The  vessel  is,  indeed,  about  |-  of  an  inch  posterior 
to  that  body,  and  is  in  comparatively  little  danger  of 
being  wounded  when  the  tonsil  is  excised.  The  internal 
jugular  vein  is  a  considerable  distance  from  the  tonsil. 
The  facial  artery,  in  its  cervical  stage,  is  close  to  the 
tonsil.  Of  important  cervical  structures,  the  nearest 
to  the  tonsil  is  the  glosso-pharyngeal  nerve.  The 
ascending  pharyngeal  artery  is  also  in  close  relation 
with  it.  Although  of  small  size,  bleeding  from  this 
vessel  has  proved  fatal,  as  the  following  interesting 
case,  reported  by  Mr.  Morrant  Baker,  will  show :  A 
man,  aged  23,  fell  when  drunk,  and  grazed  his  throat 
with  the  end  of  a  tobacco-pipe  he  was  smoking  at  the 
time.  He  thought  nothing  of  the  accident.  In  two 
days  he  came  to  the  hospital  with  what  appeared  to  be 
an  acutely  inflamed  tonsil.  The  tonsil  was  punctured, 
but  nothing  escaped  save  a  little  blood.  Several 
haemorrhages  occurred  from  the  tonsil  wound,  and  on 
the  fourth  day  after  the  accident  1  inch  of  the  stem 
of  a  clay  pipe  was  discovered  deeply  embedded  in  the 
glandular  substance.     It  was  removed,  and  the  common 


Chap,  ix.]  The   Neck.  135 

carotid  tied.  The  patient,  however,  never  rallied  from 
the  previous  severe  hemorrhages,  and  soon  died.  The 
autopsy  showed  that  the  stem  of  the  pipe,  which  had 
not  heen  missed  by  the  patient,  had  divided  the  ascending 
pharyngeal  artery  (St.  Bart's  Hosp.  Reports,  1876). 

The  tonsil  is  often  the  seat  of  malignant  growths. 
Such  tumours  have  been  removed  through  the  mouth, 
but  are  more  conveniently  dealt  with  through  an  in- 
cision in  the  neck  along  the  anterior  edge  of  the  sterno- 
mastoid  (Cheever's  operation). 


CHAPTER    IX. 

THE    NECK. 

Surface  anatomy;  bony  points. — The  hyoid 
bone  is  on  a  level  with  the  fourth  cervical  vertebra, 
while  the  cricoid  cartilage  is  opposite  the  sixth.  The 
upper  margin  of  the  sternum  is  on  a  level  with  the 
disc  between  the  second  and  third  dorsal  vertebra?. 
(See  page  169.)  At  the  back  of  the  neck  there  is  a 
slight  depression  in  the  middle  line  which  descends 
from  the  occipital  protuberance,  and  lies  between  the 
prominences  formed  by  the  trapezius  and  complexus 
muscles  of  the  two  sides.  At  the  upper  part  of  this 
depression  the  spine  of  the  axis  can  be  made  out  on 
deep  pressure.  Below  this,  the  bony  ridge  formed  by 
the  spines  of  the  third,  fourth,  fifth,  and  sixth  cervical 
vertebrae  can  be  felt,  but  the  individual  spines  cannot 
usually  be  distinguished.  At  the  root  of  the  neck  the 
spinous  process  of  the  vertebra  prominens  is  generally 
very  obvious.  The  transverse  process  of  the  atlas  may 
be  felt  just  below  and  in  front  of  the  tip  of  the  mastoid 
process.  By  deep  pressure  in  the  upper  part  of  the 
supraclavicular  fossa,  the  transverse  process  of  the 
seventh  cervical  vertebra  can  be  distinguished.  If 
deep  pressure  be  made  over  the  line  of  the  carotid 
vessels  at  the  level  of  the  cricoid  cartilage,  the  promi- 
nent anterior  tubercle  of  the  transverse  process  of  the 


136  Surgical   Applied   Anatomy.      [Chap.  ix. 

sixth  cervical- vertebra  can  be  felt.  This  is  known  as 
the  "  carotid  tubercle."  The  carotid  artery  lies  directly 
over  it,  and  in  ligaturing  that  vessel  some  surgeons 
make  important  use  of  this  tubercle  as  a  landmark.  If 
a  horizontal  section  of  the  neck,  in  a  muscular  subject, 
taken  about  the  level  of  the  sixth  cervical  vertebra,  be 
viewed,  the  whole  of  the  body  of  the  vertebra  divided  will 
be  seen  to  lie  within  the  anterior  half  of  the  section. 

The  middle  line. — In  the  receding  angle  below 
the  chin  the  hyoid  bone  can  be  felt  and  its  body  and 
greater  cornua  well  made  out.  About  a  finger's  breadth 
below  it  is  the  thyroid  cartilage.  The  details  of  this  latter 
are  readily  distinguished,  and  below  it  the  cricoid  cartil- 
age, crico-thyroid  space,  and  trachea  can  be  easily 
recognised.  The  separate  rings  of  the  trachea  cannot 
be  felt.  The  trachea  is  less  easily  made  out,  as  it  passes 
down  the  neck.  As  it  descends  it  takes  a  deeper  position, 
and  at  the  upper  border  of  the  sternum  lies  nearly  \\ 
inches  from  the  surface. 

The  rima  glottidis  corresponds  to  the  middle  of  the 
anterior  margin  of  the  thyroid  cartilage. 

Unless  enlarged,  the  thyroid  gland  cannot  be  made 
out  with  certainty.  According  to  Mr.  Holden,  the 
pulse  of  the  superior  thyroid  artery  can  be  felt  at  its 
upper  and  anterior  part. 

The  anterior  jugular  veins  descend  on  either  side 
of  the  middle  line  upon  the  sterno-hyoid  muscles.  They 
commence  in  the  submaxillary  region,  pierce  the  fascia 
just  above  the  inner  end  of  the  clavicle,  and,  passing 
behind  the  origin  of  the  sterno-mastoid  muscle,  are 
lost  to  view.  The  inferior  thyroid  veins  lie  in  front 
of  the  trachea,  below  the  isthmus. 

The  side  of  the  neck. — Muscles.  The  sterno- 
mastoid  muscle,  especially  in  thin  subjects  and  when 
thrown  into  action,  is  a  prominent  feature  in  the  neck. 
The  anterior  border  of  the  muscle  is  very  distinct.  The 
posterior  border  is  less  prominent,  especially  at  its  upper 
part.  A  communicating  branch  from  the  facial  vein 
generally  runs  along  the  anterior  border  of  the  muscle 
to  meet  the  anterior  jugular  vein  at  the  lower  part  of 


Chap,  ix.]  The   Neck.  137 

the  neck.  The  interval  between  the  sternal  and  clav- 
icular parts  of  the  muscle  is  generally  well  marked.  If 
a  needle  be  thrust  through  this  interval,  quite  close  to 
the  clavicle,  it  would  just  touch  the  bifurcation  of  the 
innominate  artery  on  the  right  side  and  would  pierce 
the  carotid  vessel  on  the  left.  The  posterior  belly  of  the 
digastric  muscle  corresponds  to  a  line  drawn  from  the 
mastoid  process  to  the  anterior  part  of  the  hyoid  bone. 
The  anterior  belly  of  the  omo-hyoid  follows  an  oblique 
line  drawn  downwards  from  the  fore  part  of  the  hyoid 
bone,  so  as  to  cross  the  line  of  the  carotid  artery  opposite 
the  cricoid  cartilage.  The  posterior  belly  can  be  made 
out  in  thin  necks,  especially  when  in  action,  running 
nearly  parallel  with  and  just  above  the  clavicle. 
Although  not  taking  quite  the  same  direction,  yet  the 
posterior  borders  of  the  sterno-mastoid  and  anterior 
scalene  muscles  practically  correspond  to  one  another. 
Vessels. — The  common  carotid  artery  is  represented 
by  a  line  drawn  from  the  sterno-clavicular  joint  to  a 
point  midway  between  the  angle  of  the  jaw  and  the 
mastoid  process.  The  vessel  bifurcates  at  the  upper 
border  of  the  thyroid  cartilage,  or  not  unfrequently 
nearly  \  an  inch  above  that  point.  The  omo-hyoid 
crosses  it  opposite  the  cricoid  cartilage,  and  at  about 
the  same  level  the  artery  is  crossed  by  the  middle  thyroid 
vein.  The  line  of  the  internal  jugular  vein  is  just 
external  to  that  for  the  main  artery.  Both  the  artery 
and  vein  lie  under  the  anterior  border  of  the  sterno- 
mastoid.  The  superior  thyroid  artery  comes  off  just 
below  the  great  eornu  of  the  hyoid  bone,  and  curves 
forwards  and  downwards  to  the  upper  edge  of  the 
thyroid  cartilage.  The  lingual  arises  opposite  the  tip 
of  the  great  cornu,  and  runs  just  above  that  process  on 
its  way  to  the  tongue.  The  facial  artery  is  very  tortuous, 
but  its  general  course  in  the  neck  is  represented  by  a 
line  drawn  from  the  anterior  border  of  the  masseter 
at  the  lower  border  of  the  jaw  to  a  point  just  above  the 
tip  of  the  great  cornu,  while  the  occipital  follows  a  line 
that  starts  from  the  latter  point  and  runs  across  the 
base  of  the  mastoid  process. 


138  Surgical   Applied  Anatomy.     [Chap.  ix. 

,The  external  jugular  vein  follows  a  line  drawn  from 
the  angle  of  the  jaw  to  the  middle  of  the  clavicle. 

The  subclavian  artery  describes  a  curve  at  the  base 
of  the  posterior  triangle.  One  end  of  the  curve  corre- 
sponds to  the  sterno-clavicular  joint,  the  other  end  to  the 
centre  of  the  clavicle,  the  summit  of  the  curve  rising 
to  a  point  about  \  an  inch  above  that  bone.  In  the  angle 
between  the  posterior  edge  of  the  sterno-mastoid  and 
the  clavicle  the  pulsations  of  the  artery  may  be  felt. 
Just  above  the  bone  the  artery  may  be  compressed 
against  the  first  rib.  The  compression  is  most  easily 
applied  when  the  arm  is  well  drawn  down,  and  the 
direction  of  the  pressure  should  be  downwards  and 
inwards. 

The  subclavian  vein  lies  below  the  artery,  and  is 
entirely  under  cover  of  the  clavicle. 

The  suprascapular  and  transverse  cervical  arteries 
run  parallel  with  the  clavicle,  the  former  quite  behind 
the  bone,  the  latter  just  above  it.  The  pulsations  of 
the  latter  vessel  can  generally  be  felt. 

Nerves. — The  position  of  the  chief  superficial  nerves 
of  the  neck  may  be  fairly  indicated  by  six  lines,  all  drawn 
from  the  middle  of  the  posterior  border  of  the  sterno- 
mastoid  muscle.  A  line  drawn  forwards  from  this  spot 
so  as  to  cross  the  sterno-mastoid  at  right  angles  to  its 
long  axis  corresponds  to  the  superficial  cervical  nerve. 
A  second  line  drawn  up  across  the  muscle  to  the  back 
of  the  pinna,  so  as  to  run  parallel  with  the  external 
jugular  vein,  corresponds  to  the  great  auricular  nerve  ; 
and  a  third  line,  running  along  the  posterior  border  of 
the  sterno-mastoid  muscle  to  the  scalp,  marks  the  course 
of  the  small  occipital  nerve.  These  lines,  continued 
downwards,  so  as  to  cross  the  sternum,  the  middle  of  the 
clavicle,  and  the  acromion,  will  indicate  respectively 
the  suprasternal,  supraclavicular,  and  supra-acromial 
nerves. 

The  spinal  accessory  nerve  reaches  the  anterior 
border  of  the  sterno-mastoid  muscle  at  a  point  about 
1  inch  below  the  tip  of  the  mastoid  process.  It  emerges 
from  beneath  that  muscle  about  the  middle  of  its  pos- 


Chap,  ix.]  The   Neck.  139 

terior  border,  crosses  the  posterior  triangle,  and  passes 
beneath  the  trapezius  at  a  point  between  the  middle 
and  lower  thirds  of  the  anterior  border  of  that  muscle. 

The  phrenic  nerve  commences  deeply  at  the  side 
of  the  neck,  about  the  level  of  the  hyoid  bone,  and  runs 
downwards  to  a  point  behind  the  sternal  end  of  the 
clavicle.  About  the  level  of  the  cricoid  cartilage  it  lies 
beneath  the  sterno-mastoid  (which  covers  it  wholly  in 
the  neck)  about  midway  between  the  anterior  and 
posterior  borders  of  the  muscle.  The  brachial  plexus 
can  be  felt,  and  even  seen  in  very  thin  subjects.  Its 
upper  limits  may  be  represented  by  a  line  drawn  across 
the  side  of  the  neck  from  a  point  about  opposite  to  the 
cricoid  cartilage  to  a  spot  a  little  external  to  the  centre 
of  the  clavicle. 

The  neck. — The  skin  in  the  submaxillary  region 
is  lax  and  thin,  and  is  often  found  o."  considerable  value 
for  making  flaps  in  plastic  operations  about  the  mouth. 
The  platysma  myoides  is  closely  connected  with  the 
skin,  and  to  its  action  is  due  the  turning-in  of  the  edges 
of  such  wounds  as  are  athwart  the  line  of  direction  of  the 
muscle.  The  amount  of  subcutaneous  fat  in  the  cervical 
region  varies  in  different  parts.  In  the  suprahyoid 
region  it  is  apt  to  undergo  extensive  development,  pro- 
ducing the   diffused  lipoma  known  as   "  double-chin." 

The  skin  over  the  nape  of  the  neck  is  very  dense 
and  adherent,  and  these  two  circumstances,  in  addition 
to  the  free  nerve-supply  of  the  parts,  serves  to  explain 
the  severe  pain  that  often  accompanies  inflammation 
in  this  region.  Common  carbuncle  is  very  commonly  met 
with  behind  at  the  root  of  the  neck,  in  the  middle  line. 
Why  it  especially  selects  this  spot  it  is  difficult  to  say. 
It  may  be  noted,  however,  that  this  region  has  no  very 
extensive  blood  supply,  that  the  middle  line  of  the  body 
'is  in  all  parts  of  comparatively  slight  vascularity,  and 
that  at  the  nape  of  the  neck  covered  and  uncovered  parts 
of  the  body  meet,  so  that  the  spot  is  liable  to  considerable 
fluctuations  of  temperature.  Setons  and  issues  were, 
in  less  recent  times,  often  applied  to  the  dense  integu- 
ments at  the  back  of  the  neck,  just  below  the  occiput. 


i4o  Surgical   Applied   Anatomy.      [Chap.  ix. 

These  measures  were  accredited  with  not  infrequently 
producing  tetanus. 

When  the  steriio-mastoid  muscle  of  one  side  is 
rigidly  contracted,  either  from  paralysis  of  the  opposite 
muscle  or  from  spasmodic  contraction,  or  from  some 
congenital  defect,  the  condition  known  as  wry-neck  is 
produced.  The  position  of  the  head  in  wry-neck  illus- 
trates precisely  the  effect  of  the  sterno-mastoid  when  in 
full  action.  The  head  is  bent  a  little  forwards,  the 
chin  is  turned  towards  the  sound  side,  and  the  ear  on  the 
affected  side  leans  towards  the  sterno-clavicular  joint. 
In  many  cases  the  trapezius  and  scalene  muscles  are  also 
affected.  Spasmodic  contraction  of  the  muscle  may  be 
due  to  reflex  irritation.  Thus,  it  has  accompanied 
inflammation  of  the  cervical  glands  in  the  posterior 
triangle.  Such  inflammation  has  irritated  some 
branches  of  the  cervical  plexus,  and  the  sterno-mastoid 
muscle,  although  it  is  supplied  mainly  by  the  spinal 
accessory  nerve,  receives  a  nerve  from  that  plexus  (viz., 
from  the  second  cervical).  The  course  of  the  reflex 
disturbance  in  such  cases  is  therefore  not  difficult  to 
follow.  It  is  to  be  remembered,  also,  that  the  spinal 
accessory  nerve  passes  between  the  upper  two  or  three 
deep  cervical  lymph  glands  which  may  compress  it. 
A  like  contraction  has  also  been  produced  by  direct 
irritation  of  the  second  cervical  nerve  in  cases  of  disease 
of  the  first  two  cervical  vertebrse.  For  the  relief  of  some 
forms  of  wry-neck,  the  sterno-mastoid  muscle  is  divided 
subcutaneously,  as  in  an  ordinary  tenotomy  operation, 
about  -|  an  inch  above  its  attachment  to  the  sternum 
and  clavicle.  Two  structures  stand  considerable  risk  of 
being  wounded  in  this  operation,  viz.,  the  external 
jugular  vein  lying  near  the  posterior  border  of  the 
muscle,  and  the  anterior  jugular  which  follows  its  an- 
terior border  and  passes  behind  the  muscle,  just  above 
the  clavicle,  to  terminate  in  the  first-named  vein.  With 
common  care,  there  should  be  no  risk  of  wounding 
the  great  vessels  at  the  root  of  the  neck.  For  spasmodic 
wry-neck  the  spinal  accessory  nerve  and  the  communi- 
cating branches  of  the  third  and  fourth  cervical  nerves 


chap,  ix.]  The    Neck.  141 

have  been  cut.  The  .spinal  accessory  nerve  is  found 
at  the  anterior  border  of  the  sterno-mastoid,  li  inches 
below  the  mastoid  process. 

There  is  a  curious  congenital  tumour,  or  indura- 
tion, sometimes  met  with  in  this  muscle  in  the  newly 
born.  It  is  usually  ascribed  to  syphilis,  but,  in  most 
cases,  is  probably  due  to  some  tearing  of  the  muscle 
fibres  during  the  process  of  delivery. 

The  cervical  fascia. — The  layers  of  fascia  that 
occupy  the  neck,  and  that  are  known  collectively  as 
the  deep  cervical  fascia,  are  dense  structures,  having  a 
somewhat  complex  arrangement  and  a  great  amount 
of  importance  from  a  surgical  point  of  view.  This 
fascia  limits  the  growth  of  cervical  tumours  and 
abscesses,  and  modifies  the  direction  of  their  progress, 
but  I  do  not  think  that  its  effect  in  this  matter  is  quite 
so  definite  as  is  usually  maintained.  It  is  true  that  deep- 
seated  cervical  abscesses  are  often  found  to  foUow  just 
such  a  course  as  the  arrangement  of  the  fascia?  would 
lead  us  to  suppose,  while,  on  the  other  hand,  instances 
are  by  no  means  uncommon  where  the  abscess  or  growth 
appears  to  ignore  these  membranes  and  adopt  a  course 
of  its  own. 

The  deep  cervical  fascia  may  be  divided  into  (a) 
the  superficial  layer,  and  (6)  the  deeper  processes. 

(a)  The  superficial  layer  forms  a  complete  investment 
for  the  neck,  and  covers  in  all  the  cervical  structures, 
except  the  platysma  and  some  superficial  veins  and 
nerves,  with  the  completeness  of  a  perfectly  fitting 
cravat.  It  commences  behind  at  the  spinous  processes 
of  the  vertebra,  and,  having  invested  the  trapezius 
muscle,  starts,  at  the  anterior  border  of  that  muscle, 
as  a  single  layer,  to  cross  the  posterior  triangle.  Arriving 
at  the  posterior  border  of  the  sterno-mastoid  muscle, 
it  splits,  to  enclose  that  structure,  appearing  again 
as  a  single  layer  at  the  anterior  border  of  the  muscle, 
from  whence  it  passes  to  the  middle  line  of  the  neck 
to  join  the  fascia  of  the  opposite  side,  entirely  covering 
in  on  its  way  the  anterior  triangle.  The  part  that 
occupies   the   posterior   triangle   is   attached   above    to 


142 


Surgical   Applied   Anatomy.      [Chap.  ix. 


the  mastoid  process  and  superior  curved  line  of  the 
occipital  bone,  and  below  to  the  clavicle,  so  that  the 
space  is  completely  closed  in  by  the  fascia  in  all  parts, 
although,  just  above  the  clavicle,  it  is  pierced  by  the 
external  jugular  vein  on  its  way  to  the  deeper  trunks. 
Over  the  anterior  triangle,  the  fascia  is  attached  above 
to  the  border  of  the  lower  jaw.  Behind  that  bone 
it  passes  over  the  parotid  gland  to  the  zygoma,  forming 
the  parotid  fascia,  while  a  deeper  layer  passes  beneath 
the  gland  (between  it  and  its  submaxillary  colleague), 
to  be  attached  to  points  at  the  base  of  the  skull.  It 
is  from  this  deeper  part  that  the  stylo-maxillary  ligament 
is  developed.  In  front  the  fascia  is  attached  to  the 
hyoid  bone,  and  just  below  the  thyroid  body  it  divides 
into  two  layers  again,  one  to  be  attached  to  the  front 
of  the  sternum  and  the  other  to  the  back.      Both  these 


Eig.  20.— Transverse  Section  through  the  lower  part  of  the  Neck,  to 
show  the  arrangements  of  the  Cervical  Fascia  (Diagrammatic}. 

a,  Trapezius;  5,  sterno-mastoid ;  c,  depressors  of  hyoid  hone;  d,  platysiua; 
e,  anterior  spinal  muscles ;  /,  scalenus  anticus  ;  cj,  carotid  artery  ;  ft,  external 
jugular  vein  ;  i,  posterior  spinal  muscles;  t,  trachea,  with  gullet  behind  and 
thyroid  body  in  front. 


Chap,  ix.]  The   Neck.  143 

layers  lie  in  front  of  the  depressors  of  the  hyoid  bone, 
and  they  form  between  them  a  little  space  (which 
extends  so  far  laterally  as  to  enclose  the  sternal  head 
of  the  sterno-mastoid),  the  widest  part  of  which  is  below, 
and  which  there  corresponds  in  width  to  the  thickness 
of  the  sternum.  It  will  be  perceived  that,  in  dividing 
the  sternal  head  of  the  sterno-mastoid,  the  operation 
is  performed  within  this  little  chamber  formed  by  the 
two  layers  just  named,  and  it  is  well  to  note  that  the 
anterior  jugular  vein  also  occupies  this  chamber  on 
its  way  to  the  external  jugular  trunk.  This  superficial 
layer  of  the  fascia,  considered  generally,  would  oppose 
in  all  parts  the  progress  of  abscesses  or  growths  towards 
the  surface,  and  would  encourage  or  compel  them  to 
take  a  deeper  position. 

(6)  The  deeper  processes.  (1)  From  the  superficial 
layer  a  process  comes  off  near  the  anterior  border  of 
the  sterno-mastoid  muscle,  which,  passing  beneath 
the  depressors  of  the  hyoid  bone,  invests  the  thyroid 
body  and  front  of  the  trachea,  and  passes  down,  in 
front  of  that  tube  and  of  the  large  vessels,  to  the  fibrous 
layer  of  the  pericardium.  (2)  The  prevertebral  fascia 
is  a  layer  that  descends  on  the  prevertebral  muscles 
behind  the  pharynx  and  gullet.  It  is  attached  above 
to  the  base  of  the  skull,  and,  below,  descends  into  the 
thorax,  behind  the  cesophagus.  Laterally,  it  joins  the 
carotid  sheath,  and  is  then  prolonged  outwards  and 
downwards  over  the  scalene  muscles,  the  brachial 
plexus,  and  subclavian  vessels.  It  follows  these  vessels 
beneath  the  clavicle,  where  it  forms  the  axillary  sheath 
and  becomes  connected  with  the  under  surface  of  the 
costo-coracoid  membrane.  (3)  The  sheath  of  the  carotid 
artery  and  its  accompanying  vein  and  nerve  are  derived 
in  part  from  fascia  No.  1,  and  in  part  from  fascia 
No.  2. 

The  effects  of  this  disposition  of  the  fascia  may  be 
illustrated  by  noting  the  course  probably  taken  by 
cervical  abscesses  in  various  positions.  (1)  ;An  abscess 
in  the  posterior  triangle  will  be  bounded  towards  the 
surface   by   the   superficial   layer   of   fascia.     Towards 


144  Surgical   Applied   Anatomy.      [Chap.  ix. 

the  floor,  or  deep  part,  of  the  triangle  it  will  be  bounded 
by  the  lateral  portion  of  fascia  No.  2.  The  abscess 
may  extend  some  way  under  the  clavicle  until  arrested 
by  the  union  of  the  costo-coracoid  membrane  with 
fascia  No.  2.  It  would  readily  extend  under  the  edge 
of  the  trapezius  muscle,  and  could  pass  beneath  the 
sterno-mastoid  muscle  and  carotid  artery  to  the  anterior 
and  deeper  parts  of  the  neck.  (2)  An  abscess  in  the 
anterior  triangle  in  front  of  the  depressors  of  the  hyoid 
bone  would  probably  come  forward,  owing  to  the 
thinness  of  the  fascia  in  front  of  it :  but,  if  pent  up, 
it  would  tend  to  progress  towards  the  anterior  medias- 
tinum or  into  the  lateral  parts  of  the  neck  in  front 
of  the  carotid  vessels.  (3)  An  abscess  behind  the  hyoid 
depressors  and  about  the  trachea  or  thyroid  body, 
or  in  the  immediate  vicinity  of  the  carotid  vessels  (an 
abscess  situate,  in  fact,  between  the  deep  fasciae  Nos. 
1  and  2),  would  find  itself  in  a  narrow  strait,  and  after 
pressing  much  upon  adjacent  parts  would  most  readily 
spread  downwards  into  the  mediastinum.  (4)  An 
abscess  immediately  in  front  of  the  spine,  and  beneath 
the  deep  fascia  No.  2,  might  extend  down  into  the 
posterior  mediastinum,  or  move  towards  the  posterior 
and  lateral  parts  of  the  neck,  following  the  brachial  plexus, 
and  so  reach  the  posterior  triangle,  or  even  the  axilla. 
In  many  cases  a  cervical  abscess  has  burst  into  the 
gullet,  or  trachea,  and  even  into  the  pleura.  In  some 
instances  the  great  vessels  have  been  opened  up.  In 
one  remarkable  case  reported  by  Mr.  Savory  {Med. 
Chir.  Trans.,  1881),  not  only  was  a  considerable  portion 
of  the  common  carotid  artery  destroyed  by  the  abscess, 
but  also  a  still  larger  portion  of  the  internal  jugular 
vein  and  a  large  part  of  the  vagus  nerve.  This,  and 
like  examples  of  the  destructive  action  of  some  cervical 
abscesses,  depend,  no  doubt,  upon  the  unyielding 
character  of  the  cervical  fascia,  which  hems  in  the  pus 
on  all  sides,  and  drives  it  to  resort  to  desperate  measures 
to  effect  an  escape.  "  It  is  noteworthy,"  remarks  Mr. 
Jacobson,  "  that  communications  between  abscesses  and 
deep  vessels  have  usually  taken  place  beneath  two  of 


Ch  ap.  i  x .  ]  The    Neck,  i  4  5 

the  strongest  fasciae  in  the  body,  the  deep  cervical  fascia 
a  ad  the  fascia  lata  "  (Hilton's  "  Eest  and  Pain  "). 

The  apex  of  the  lung  extends  into  the  neck, 
and  reaches  a  point  from  1  to  2  inches  above  the 
anterior  end  of  the  first  rib.  A  point  between  the 
sternal  and  clavicular  heads  of  the  sterno-mastoid  and 
\  an  inch  above  the  clavicle  will  mark  its  highest 
limit.  It  lies  behind  the  clavicle,  anterior  scalene 
muscle,  and  subclavian  vessels.  The  right  lung  com- 
monly extends  higher  up  than  the  left. 

The  pleura  has  been  opened  in  careless  operations 
on  the  subclavian  artery,  and  has  also  been  torn  in 
dragging  deep-seated  tumours  from  the  base  of  the 
neck.  The  pleura  and  lung  have  been  wounded  in 
stabs  of  the  neck  and  by  fragments  of  bone  in  severe 
fractures  of  the  clavicle.  Cervical  abscesses  have  opened 
into  the  pleura,  and,  apart  from  this,  pleurisy  has  followed 
inflammation  of  the  cellular  tissue  at  the  root  of  the 
neck. 

Hernia  of  the  lung  into  the  neck  has  occurred  during 
violent  coughing,  an  appreciable  tumour  being  produced 
(Dr.  Knox,  Lancet,  vol.  i.  ;   1885). 

Cervical  ribs.— These  structures  have  led  to 
many  errors  in  diagnosis,  have  been  mistaken  for  ex- 
ostoses, and  where  the  subclavian  artery  is  carried 
over  them  have  led  to  the  diagnosis  of  aneurism.  They 
are  met  with  at  all  ages  and  in  both  sexes,  and  represent 
the  cervical  ribs  of  lower  vertebrates.  As  a  rule,  one 
such  rib  is  found  on  either  side  of  the  seventh  cervical 
vertebra ;  sometimes  it  is  movable,  sometimes  it  is 
ankylosed  to  the  vertebra  and  its  transverse  process. 
A  vestige  is  always  present  in  the  fcetus.  It  may  be 
very  short,  and  represented  only  by  a  head,  neck,  and 
tubercle.  Such  forms  have  been  mistaken  for  exostoses. 
It  may  be  long,  and  may  then  end  free,  or  be  joined 
to  the  first  rib,  or  the  first  costal  cartilage  by  ligament, 
or  even  by  cartilage.  In  such  instances  the  subclavian 
artery  passes  over  the  cervical  rib,  and  its  distinct 
pulsation  under  such  circumstances  has  led  to  the 
diagnosis  of  aneurism.     To  the  longer  form  of  cervical 

K 


146  Surgical    Applied   Anatomy.      [Chap.  ix. 

ribs  the  scalenus  anticus,  and  the  scalenus  medius, 
may  be  attached. 

In  thin  subjects  the  rib  forms  a  distinct  projection 
in  the  neck. 

Cut  throat  and  wounds  of  the  neck. — The 
skin  of  the  neck  is  so  elastic  and  mobile  that  it  is  readily 
thrown  into  folds  when  a  knife,  and  especially  a  blunt 
knife,  is  drawn  across  it.  Thus,  in  cases  of  cut  throat 
several  distinct  skin  cuts  may  be  found  that  were  all 
produced  by  one  movement  of  the  knife.  The  wound 
in  cut  throat,  whether  suicidal  or  homicidal,  most  fre- 
quently involves  the  thyro-hyoid  membrane,  next  in 
frequency  the  trachea,  and  then  the  thyroid  cartilage. 

1.  If  the  wound  be  above  the  hyoid  bone  the 
following  parts  may  be  cut :  Anterior  jugular  vein  ; 
anterior  belly  of  digastric ;  mylo-hyoid,  genio-hyoid, 
genio-hyo-glossus,  and  hyo-glossus  muscles  ;  the  lingual 
artery  ;  branches  of  the  facial  artery  ;  the  hypoglossal 
and  gustatory  nerves ;  the  submaxillary  gland.  The 
substance  of  the  tongue  may  be  cut,  and  the  floor  of 
the  mouth  freely  opened.  In  any  case  where  the  attach- 
ments of  the  tongue  are  divided  the  organ  is  apt  to 
fall  back  upon  the  larynx  and  produce  suffocation. 

2.  If  the  wound  be  across  the  thyro-hyoid  space 
the  following  may  be  the  parts  cut :  Anterior  jugular 
vein ;  sterno-hyoid,  thyro-hyoid,  omo-hyoid  muscles ; 
thyro-hyoid  membrane  ;  inferior  constrictor  ;  superior 
laryngeal  nerve  ;  superior  thyroid  artery  ;  and  if  near 
hyoid  bone  the  trunk  of  the  lingual  artery  may  be  cut. 
The  pharynx  would  be  opened  in  a  deep  wound,  and 
the  epiglottis  divided  near  its  base.  Division  of  the 
epiglottis  in  wounds  in  this  situation  is  always  a  serious 
complication. 

3.  If  the  wound  involve  the  trachea  the  following 
may  be  the  parts  cut :  Anterior  jugular  vein  ;  sterno- 
hyoid, sterno-thyroid,  and  omo-hyoid  muscles  ;  part  of 
sterno-mastoid  ;  thyroid  gland  ;  superior  and  inferior 
thyroid  arteries  ;  superior,  middle,  and  inferior  thyroid 
veins  ;   recurrent  nerves  and  the  gullet. 

In  wounds  of  the  neck  the  great  vessels  often  escape 


Chap  ix."  The   Neck.  147 

in  a  marvellous  manner.     They  are  protected  in  part 

by  the  depth  at  which  they  are  situated,  and  in  part  by 
their  great  mobility,  lying  as  they  do  in  an  atmosphere 
of  loose  connective  tissue.  Dieffenbaeh  relates  a  case  of 
cut  throat  in  which  both  gullet  and  trachea  were  divided 
without  any  damage  to  the  great  vessels.  In  cut  throat 
the  vessels  are  greatly  protected  by  the  projecting  thyroid 
cartilage  above  and  by  the  contracting  of  the  sterno- 
rnastoid  muscles  below.  Deep  gashes  made  across  the 
crico-thyroid  space,  or  through  the  upper  part  of  the 
trachea,  reach  the  great  vessels  more  easily  than  would 
wourids  made  with  equal  force  in  any  other  part  of  the 
neck. 

In  some  cases  of  gunshot  wound  the  vessels  -trem 
to  have  been  actually  pushed  aside,  and  to  have  owed 
their  safety  to  their  mobility.  Thus,  in  a  case  reported 
by  Longmore,  the  bullet  passed  entirely  through  the 
neck  from  one  side  to  the  other.  It  passed  through  the 
gullet,  damaged  the  posterior  part  of  the  larynx,  but 
left  the  great  vessels  intact.  In  another  recorded  case 
a  boy  fell  upon  the  point  of  a  walking-stick.  The  end 
of  the  stick  passed  entirely  through  the  neck  from  side 
to  -ide,  entering  in  front  of  one  sterno-mastoid  muscle 
and  emerging  through  the  substance  of  the  opposite  one. 
It  probably  passed  between  the  pharynx  and  the  spine. 
The  boy,  who  left  the  hospital  well  in  eighteen  days, 
owed  his  safety  to  the  laxity  of  the  cervical  connective 
tissue  and  to  the  mobility  of  the  main  structures  in  the 
neck. 

In  connection  with  the  subject  of  wounds  of  the 
neck  it  must  be  remembered  that  the  most  important 
part  of  the  spinal  cord  can  be  reached  from  behind, 
through  the  gap  between  the  atlas  and  axis.  In  this 
situation  the  cord  has  been  divided  by  one  stab  of  a 
knife,  the  instrument  entering  between  the  two  bones. 
Langier  gives  some  ingenious  cases  of  infanticide  where 
the  lethal  weapon  was  merely  a  long  needle.  The  needle 
was  introduced  into  the  spinal  canal  between  the  atlas 
and  axis,  and  the  cord  readily  cut  across. 

Wounds  at  the  side  of  the  neck  have  divided  con- 


148  Surgical   Applied   Anatomy.     [Chap, ix. 

siderable   portions  of  the   brachial  plexus   without  in- 
volving other  structures. 

The  liyoid  bone  may  be  broken  by  direct  violence, 
as  from  blows,  or  in  the  act  of  throttling.  It  is  sometimes 
found  broken  in  those  who  have  been  hanged.  The 
fracture  may  involve  the  body  of  the  bone,  but  more 
usually  the  greater  cornu  is  found  broken  off.  In  the 
New  York  Medical  Record  (1882)  is  the  report  of  the 
case  of  a  man  who  felt  something  snap  under  his  chin 
while  yawning.  On  examination  the  hyoid  bone  was 
found  to  be  fractured.  The  bone  was  also  found  broken 
in  a  patient  wTho  threw  her  head  violently  backwards 
to  save  herself  from  falling  (Hamilton).  The  fracture 
is  associated  with  great  difficulty  and  pain  in  speaking, 
in  moving  the  tongue,  in  opening  the  mouth,  and  in 
swallowing,  symptoms  that  may  be  readily  understood. 
A  bursa  lies  between  the  thyro-hyoid  membrane  and 
the  posterior  surface  of  the  hyoid  bone.  It  may,  when 
enlarged,  form  one  of  the  cystic  tumours  of  the  neck. 

The  larynx  and  trachea. — The  position  of  the 
larynx  in  the  neck  is  influenced  by  age.     In  the  adult 
the  cricoid  cartilage  reaches  to  the  lower  part  of  the 
sixth  cervical  vertebra.     In  a  child  of  three   months 
it  reaches  the  lower  border  of  the  fourth  cervical,  and 
in  a  child  of  six  years  the  lower  border  of  the  fifth  ver- 
tebra.    At  puberty  it  attains  the  adult  position.     The 
upper  end  of  the  epiglottis  in  the  adult  is  opposite  the 
lower  border  of  the  third  cervical  vertebra.     In  a  child 
of.  three  months  it  reaches  the  lower  border  of  the  atlas, 
and  at  six  years  the  lower  border  of  the  axis  (Symington). 
With  the  laryngoscope  the  following  parts  may  be  made 
out :   The  base  of  the  tongue  and  glosso-epiglottic  liga- 
ments ;   the  superior  aperture  of  the  larynx,  presenting 
in  front  the  epiglottis,  at  the  sides  the  aryteno-epiglot- 
tidean  folds  (in  which  are  two  rounded  eminences  corre- 
sponding  to   the  cornicula  and  cuneiform   cartilages), 
and  at  the  back  the  arytenoid  commissure  of  mucous 
membrane.     Deeply  clown  can  be  seen  the  true  and  false 
vocal  cords,  the  ventricle,  the  anterior  wall  of  the  larynx, 
a  little  of  the  cricoid  cartilage,  and  more  or  less  of  the 


chap,  ix.]  The   Neck.  149 

anterior  wall  of  the  trachea.  If  the  glottis  be  very  fully 
dilated  the  openings  of  the  two  bronchi  may  be  dimly 
seen. 

The  thyroid  and  cricoid  cartilages,  and  the  greater 
part  of  the  arytenoid,  are  in  structure  hyaline,  as  are 
the  costal  cartilages.  Like  the  last-named,  they  are 
liable  to  become  more  or  less  ossified  as  life  advances. 
Ossification  commences  in  the  thyroid  and  cricoid  car- 
tilages at  about  the  age  of  20,  and  in  either  cartilage 
the  process  commences  in  the  vicinity  op  the  crico- 
thyroid joint.  The  arytenoid  ossifies  later.  Ossifica- 
tion of  the  laryngeal  cartilages  is  more  marked  in  males 
than  in  females.  The  larger  cartilages  are  liable  to  be 
fractured  by  violence,  as  by  blows,  throttling,  etc.  The 
thyroid  is  the  one  most  frequently  broken,  and  usually 
in  the  median  line.  The  posterior  superior  angle  of  the 
thyroid  cartilage  marks  the  position  of  the  pyriform 
fossa,  a  wide  recess,  above  and  external  to  the  aryteno- 
epigiottic  folds.  Foreign  bodies  may  be  arrested  in  this 
fossa. 

The  rima  glottidis  is  the  aperture  between  the 
true  vocal  cords  in  front  and  the  bases  of  the  arytenoid 
cartilages  behind.  It  is  the  narrowest  part  of  the  in- 
terior of  the  larynx,  and  it  is  well  to  be  familiar  with  its 
proportions  in  reference  to  the  entrance  of  foreign  bodies 
and  the  introduction  of  instruments.  In  the  adult 
male  the  rima  measures  nearly  1  inch  (23  mm.)  from 
before  backwards ;  from  side  to  side,  at  its  widest 
part,  it  measures  about  one-third  of  the  length  ;  this 
diameter  may  be  increased  to  one-half  of  the  length 
in  extreme  dilatation.  In  the  female  and  in  the  male 
before  puberty  the  anteroposterior  diameter  is  from 
17  mm. 

The  mucous  membrane  of  the  larynx  varies 
in  thickness  in  different  parts,  and  in  the  amount  of 
its  submucous  tissue.  The  membrane  is  thickest,  and 
the  submucous  tissue  most  abundant,  in  the  following 
parts,  taken  in  order  of  degree  :  The  aryteno- 
epiglottidean  folds,  the  mucous  membrane  of  the 
ventricle,  the  false  cords,  and  the  laryngeal  aspect  of 


150  Surgical   Applied   Anatomy,      ichap.  ix. 

the  epiglottis.  These  are  the  parts  that  become  most 
congested  and  swollen  in  acute  laryngitis  ;  and  the 
serious  condition  known  as  cedema  of  the  glottis  depends 
mainly  upon  effusion  into  the  lax  submucous  tissue  in 
the  aryteno-epiglottidean  folds.  The  mucous  membrane 
is  firmly  bound  to  the  true  vocal  cords  and  covered  by 
stratified  epithelium,  while  the  rest  of  the  larynx  is 
lined,  like  the  trachea,  with  ciliated  epithelium.  Owing 
to  the  nature  of  its  covering  and  exposure  to  friction 
the  true  vocal  cord  is  not  an  uncommon  site  of  epi- 
thelioma. The  affection  known  as  "  clergyman's  sore- 
throat  "  has  an  interesting  anatomical  basis.  The 
mucous  membrane  of  the  larynx  is  well  provided  with 
mucous  glands,  whose  function  it  is  to  keep  moist  the 
parts  concerned  in  phonation.  When  an  individual 
speaks  aloud  for  a  long  time  the  lining  of  the  larynx 
tends  to  become  dry,  on  account  of  the  large  amount  of 
cold  air  that  is  drawn  in  directly  through  the  mouth. 
To  still  keep  these  parts  moist  the  mucous  glands  have 
to  exhibit  increased  energy,  and  in  those  who  speak 
much  in  public  the  glands  may  in  time  become  so  over- 
worked as  to  inflame.  It  is  the  inflammation  of  these 
glands  that  constitutes  the  present  affection.  The  glands 
are  not  distributed  equally  over  all  parts  of  the  larynx, 
but  are  most  numerous  in  the  membrane  covering  the 
arytenoid  cartilages  and  parts  immediately  about  them, 
the  base  of  the  epiglottis,  and  the  interior  of  the  ven- 
tricle. It  is  in  these  parts,  therefore,  that  the  changes 
in  chronic  glandular  laryngitis,  or  dysphonia  clericorum, 
are  most  marked. 

Excision  of  the  larynx. — The  entire  larynx 
has  been  removed  for  carcinomatous  disease,  but  the 
operation,  although  not  immediately  fatal,  has  not  been 
followed  by  very  satisfactory  results.  It  is  removed 
through  an  incision  in  the  middle  line.  In  this  in- 
cision are  divided  the  platysma,  the  fascia,  and  the 
anterior  jugular  vein.  The  larynx  is  separated  from 
its  connections,  the  following  structures  being  divided  : 
sterno-thyroid,  thyro-hyoid,  stylo-pharyngeus,  palato- 
pharyngeus,  and  inferior  constrictor  muscles,  laryngeal 


Chap,  ix.]  The   Ateck.  151 

branches  of  superior  and  inferior  thyroid  arteries, 
superior  and  inferior  laryngeal  nerves,  hyo-epiglottic 
and  glosso-epiglottic  ligaments.  The  larynx  is 
then  separated  from  the  trachea,  and  is  dis 
sected  off  from  below  up.  In  separating  the  gullet 
and  pharynx  there  is  great  risk  of  "  button-holing " 
the  former  tube.  Extirpation  of  half  the  larynx  is 
attended  with  less  risk,  and  in  early  cases  with  the  cancer 
limited  to  one  vocal  cord  it  may  be  sufficient  to  remove 
the  corresponding  parts  of  the  thyroid,  cricoid  and 
arytenoid  cartilages. 

The  lymphatic  vessels  of  the  upper  half  of  the  larynx 
follow  the  superior  laryngeal  vessels  and  pass  to  the 
upper  deep  cervical  glands.  A  small  lymphatic  gland, 
the  first  to  become  the  seat  of  secondary  cancerous 
deposit,  is  situated  below  the  horn  of  the  hyoid  on  the 
thyro-h void  membrane.  (Fig.  21,  p.  164.)  The  lymphatics 
of  the  lower  half  of  the  larynx  accompany  the  inferior 
thyroid  vessels  and  pass  through  lymph  glands  by  the 
side  of  the  trachea. 

Tracheotomy  and  laryiigotomy. — The  trachea 
is  about  A\  inches  in  length,  and  from  f  to  1  inch  in 
its  extreme  width.  It  is  surrounded  by  an  atmosphere 
of  very  lax  connective  tissue,  which  allows  a  considerable 
degree  of  mobility  to  the  tube.  The  mobility  of  the 
trachea  is  greater  in  children  than  in  adults,  and  adds 
much  to  the  difficulties  of  tracheotomy.  In  this  pro- 
cedure the  windpipe  is  opened  in  the  middle  line  by 
cutting  two  or  three  of  its  rings  above,  below,  or  through 
the  isthmus  of  the  thyroid  gland.  Since  the  trachea, 
as  it  descends,  lies  further  from  the  surface,  and  comes 
in  relation  with  more  and  more  important  structures, 
it  is  obvious  that,  other  things  being  equal,  the  higher  in 
the  neck  the  operation  can  be  done  the  better.  The  length 
of  trachea,  in  the  neck  is  not  so  considerable  as  may  at 
first  appear,  and,  according  to  Holden,  not  more  than 
some  7  or  8  of  the  tracheal  rings  (which  number  16  to 
20  in  all)  are  usually  to  be  found  above  the  sternum. 
The  distance  between  the  cricoid  cartilage  and  the  sternal 
notch  varies  greatly,  and  depends  upon  the  length  of 


152  Surgical    Applied   Anatomy.      [Chap.  ix. 

the  neck,  the  age  of  the  patient,  and  the  position  of 
the  head.  If  2  inches  of  trachea  are  exposed  above 
the  sternum  when  the  head  rests  easily  upon  the  spine, 
then  in  full  extension  of  the  head  some  f  of  an  inch 
more  of  the  windpipe  will,  as  it  were,  be  drawn  up  into 
the  neck.  According  to  Tillaux,  the  average  full  distance 
between  the  cricoid  cartilage  and  the  sternum  is,  in 
the  adult,  about  2f  inches  (7  cm.).  The  full  distance 
in  a  child  between  three  and  five  years  is  about  1^  inches 
(4  cm.),  in  a  child  between  six  and  seven  about  2  inches 
(5  cm.),  and  in  children  between  eight  and  ten  years 
about  2 \  inches  (6  cm.).  As  may  be  imagined,  the 
dimensions  of  the  trachea  on  section  vary  greatly  at 
different  ages,  and  even  in  different  individuals  of  the 
same  age.  This  leads  to  the  question  as  to  the  proper 
diameter  of  tracheotomy  tubes.  Guersant,  who  has 
paid  much  attention  to  this  matter,  says  that  the  dia- 
meter of  the  tubes  should  run  from  6  mm.  to  15  mm.* 
The  tubes  with  a  diameter  of  from  12  mm.  to  15  mm. 
are  for  adults.  The  tubes  below  12  mm.  are  for  children, 
and  are  divided  into  four  sets. 

-kt      -.    (  with  a  clia-  }  .-.  \  is  suitable  for  )ni„^T,„_„„i 

Ino    1.  <  ,         j.    >  b  mm.  \    i  --I  i         o         \  1*  to.  4  years  of  age. 

(    meter  of    )  (  children  from  ) 

No.  2.  ,,  8  mm.  „  4  to    8        ,, 

No.  3.  ,,  10  mm.  „  8  to  12 

No.  4.  ,,  12  mm.  ,,  12  to  15        ,, 

In  children  under  eighteen  months  the  diameter  of 
the  tube  should  be  about  4  mm. 

In  performing  tracheotomy  it  is  most  important  that 
the  head  be  thrown  as  far  back  as  possible,  and  that 
the  chin  be  kept  strictly  in  a  line  with  the  sternal  notch, 
so  that  the  relations  of  the  middle  line  of  the  neck  be 
preserved.  Full  extension  of  the  head  not  only  gives 
the  surgeon  increased  room  for  the  operation,  but  also 
brings  the  trachea  nearer  to  the  surface,  and  by  stretching 
the  tube  renders  it  much  less  mobile. 

In  cutting  down  upon  the  trachea  in  the  middle 
line  of  the  neck  from  the  cricoid  cartilage  to  the  sternum 

*  The  reader  may  be  reminded  that  12  mm.  =  about  h  an 
inch,  and  6  mm.,  therefore,  =  about  j  of  an  inch. 


Chap,  ix.]  The   Neck.  153 

the  following  parts  are  met  with.  Beneath  the  integu- 
ment lie  the  anterior  jugular  veins.  As  a  rule  these 
veins  lie  some  little  way  apart  on  either  side  of  the  median 
line,  and  do  not  communicate  except  by  a  large  transverse 
branch  which  lies  in  the  interfascial  space  at  the  upper 
border  of  the  sternum.  Sometimes  there  are  many 
communicating  branches  right  in  front  of  the  tracheo- 
tomy district,  or  the  veins  may  form  almost  a  plexus  in 
front  of  the  trachea,  or  there  may  be  a  single  vein  which 
will  follow  the  middle  line.  Then  comes  the  cervical 
fascia,  enclosing  the  sterno-hyoid  and  sterno-thyroid 
muscles.  The  gap  between  the  muscles  of  opposite  sides 
is  lozenge-shaped,  and  is  such  that  the  trachea  can  be 
exposed  without  dividing  muscle  fibres.  The  isthmus  of 
the  thyroid  usually  crosses  the  2nd,  3rd,  and  4th  rings 
of  the  trachea.  Above  it  a  transverse  communicating 
branch  between  the  superior  thyroid  veins  is  sometimes 
found.  Over  the  isthmus  is  a  venous  plexus,  from 
which  the  inferior  thyroid  veins  arise,  while  below  the 
isthmus  these  veins  lie  in  front  of  the  trachea  together 
with  the  thyroidea  ima  artery  (when  it  exists).  The 
inferior  thyroid  vein  may  be  represented  by  a  single 
trunk  occupying  the  middle  line.  In  the  infant  before 
the  age  of  two  years  the  thymus  extends  up  for  a  vari- 
able distance  in  front  of  the  trachea.  At  the  very  root 
of  the  neck  the  trachea  is  crossed  by  the  innominate 
and  left  carotid  arteries  and  by  the  left  innominate 
vein ;  and  lastly,  abnormal  branches  of  the  superior 
thyroid  artery  may  cross  the  upper  rings  of  the  wind- 
Pipe. 

The  evil  of  wounding  the  thyroid  isthmus  is  greatly 
exaggerated.  I  have  frequently  divided  this  structure 
in  performing  tracheotomy  without  any  inconvenience 
resulting.  Like  other  median  raphe,  the  middle  line 
of  the  thyroid  isthmus  has  but  a  slight  vascularity, 
and  it  has  been  shown  that  one  side  of  the  thyroid  gland 
cannot  be  injected  from  the  other  (i.e.  by  injection 
thai  would  cross  the  isthmus).  The  difficulty  of 
tracheotomy  in  infants  depends  upon  the  shortness 
of  the  neck,  the  amount  of   the  subcutaneous  fat,  the 


154  Surgical   Applied   Anatomy.      [Chap,  ix 

depth  at  which  the  trachea  lies,  its  small  size,  its  great- 
mobility,  and  the  ease  with  which  it  can  be  made  to 
collapse  on  pressure.  To  the  finger,  roughly  introduced, 
the  infant's  trachea  offers  little  resistance.  Its  mobility 
is  such  that  we  hear  of  its  being  held  aside  unknowingly 
by  retractors,  while  the  operator  is  scoring  the  oesophagus 
(Durham).  In  the  child,  too,  the  great  vessels  often 
cross  the  trachea  higher  up  than  in  the  adult,  and  some 
inconvenience  may  also  arise  from  an  unduly  prominent 
thymus.  In  one  case,  in  an  infant,  the  end  of  a  trache- 
otomy tube  pressing  on  the  front  of  the  trachea  produced 
an*  ulcer  that  opened  the  innominate  artery  (Brit.  Med. 
Jour.,  1885).  In  introducing  tire  cannula,  if  the  tracheal 
wound  be  missed,  it  is  easy  to  thrust  the  instrument 
into  the  lax  tissue  beneath  the  cervical  fascia  and  imagine 
that  it  is  within  the  windpipe. 

In  laryngotomy  the  air  passage  is  opened  by  a  trans- 
verse cut  through  the  crico-thyroid  membrane.  The 
crico-thyroid  space  only  measures  about  \  an  inch  in 
vertical  height  in  well-developed  adult  su bjects,  while 
in  children  it  is  much  too  small  to  allow  of  a  cannula 
being  introduced.  The  crico-thyroid  arteries  cross  the 
space,  and  can  hardly  escape  division.  They  are,  as 
a  rule,  of  very  insignificant  size,  and  give  no  trouble. 
Occasionally,  however,  these  vessels  are  large,  and 
"  cases  are  recorded  in  which  serious  and  even  fatal 
haemorrhage  has  occurred  from  these  vessels  "  (Durham). 
In  introducing  the  cannula  it  may  readily  slip  between 
the  crico-thyroid  membrane  and  the  mucous  lining 
instead  of  entering  the  trachea. 

Foreign  bodies  often  find  their  way  into  the 
air  passages,  and  have  been  represented  by  articles  of 
food,  teeth,  pills,  buttons,  small  stones,  and  the  like. 
They  are  usually  inspired  during  the  act  of  respiration, 
and  may  lodge  in  the  superior  aperture  of  the  larynx, 
or  in  the  rima,  or  find  their  way  into  the  ventricle, 
or  lodge  in  the  trachea,  or  enter  a  bronchus.  If  a  foreign 
substance  enters  a  bronchus  it  usually  selects  the  right, 
that  bronchus  having  its  aperture  more  immediately 
under  the  centre  of  tlie  trachea  than  has  the  left  tube, 


Chap,  ix.]  The   Neck.  155 

Quite  recently,  in  a  dissecting-room  subject,  I  found 
two  threepenny  pieces  lying  side  by  side,  in  the  right 
bronchus,  so  as  to  entirely  block  the  tube.  The  clanger 
of  inhaled  foreign  substances  depends  not  so  much 
upon  the  mechanical  obstruction  they  offer,  as  upon 
the  spasm  of  the  glottis  they  excite  by  reflex  irritation. 
A  body  may,  however,  lodge  in  the  ventricle  for  some 
time  without  causing  much  trouble,  as  in  a  case  reported 
by  Desault,  where  a  cherry-stone  lodged  for  two  years 
in  this  cavity  without  much  inconvenience  to  its  host. 
In  one  strange  case  a  bronchial  gland  found  its  way 
into  the  trachea  by  producing  ulceration  of  that  tube, 
was  coughed  up,  and  became  impacted  in  the  rima 
glottidis.  The  patient  was  saved  from  immediate 
suffocation  by  tracheotomy.  Foreign  bodies  have  been 
removed  from  the  right  bronchus  through  a  tracheotomy 
wound.  In  this  way  MacCormac  removed  from  the 
bronchus  the  blade  of  a  tooth  forceps. 

The  thyroid  body. — Each  lobe  should  measure 
about  2  inches  in  length,  about  \\  inches  in  breadth, 
and  f  of  an  inch  in  thickness  at  its  largest  part.  When 
distinctly  beyond  these  measurements  the  thyroid  may 
be  considered  to  be  enlarged.  Its  usual  weight  is  between 
one  and  two  ounces.  Of  its  three  surfaces,  the  anterior 
is  covered  by  the  infra-hyoid  muscles,  its  inner  rests 
on  the  larynx  and  trachea,  while  its  outer  covers  the 
carotid  sheath.  Its  prominent  posterior  border  is  in 
contact  at  its  lower  part  with  the  recurrent  laryngeal 
nerve  and  oesophagus.  Each  lobe  extends  from  about 
the  middle  of  the  thyroid  cartilage  to  the  sixth  ring 
of  the  trachea.  It  is  larger  in  females  than  in  males, 
and  the  right  lobe  is  usually  larger  than  the  left.  In 
connection  with  these  matters  it  may  be  noted  that 
thyroid  enlargements  (bronchocele,  goitre)  are  more 
common  in  females  than  in  males,  and  in  any  case  are 
more  apt  to  be  first  noticed  on  the  right  side.  The 
body  being  closely  adherent  to  the  trachea  and  larynx,  it 
follows  that  it  moves  up  and  down  during  deglutition, 
and  this  circumstance  is  of  the  utmost  value  in  the 
diagnosis  of  bronchocele  from  other  cervical  tumours. 


156  Surgical    Applied   Anatomy,      [Chap.  ix. 

The  thyroid  when  enlarged  may  distort  and  narrow 
the  trachea,  and  this  is  all  the  more  likely  to  be  the  case 
when  the  enlargement  occurs  rapidly,  since  the  body 
is  held  down  by  the  sterno-hyoid,  sterno-thyroid,  and 
omo-hyoid  muscles.  The  enlarged  gland  is  apt  to  press 
especially  upon  the  veins  of  the  neck,  producing  engorge- 
ment of  the  face  and  head,  upon  the  sterno-mastoid 
muscle,  and  the  other  muscles  named,  upon  the  cervical 
nerves,  and  particularly  the  recurrent  laryngeal.  In 
some  cases  of  dyspnoea  produced  by  rapidly  growing 
bronchoceles,  Bonnet  has  proposed  subcutaneous 
section  of  the  muscles.  Since  the  isthmus  must  bind 
together  the  enlarging  lobes  of  a  bronchocele,  Sir  Duncan 
Gibb,  on  the  other  hand,  proposed  to  divide  the  isthmus 
in  cases  where  dyspnoea  resulted.  This  operation  he 
performed  several  times  with  great  relief  to  the  patient. 
The  posterior  border  of  the  thyroid  body  being  in  contact 
with  the  sheath  of  the  great  vessels,  it  follows  that 
the  gland  when  enlarged  may  readily  receive  pulsations 
from  those  vessels.  It  generally  touches  also  the  lower 
part  of  the  pharynx,  and  the  upper  part  of  the  gullet 
behind,  and  enlargement  in  this  direction  may,  in 
connection  with  the  interference  with  the  movement 
of  the  larynx  in  deglutition,  serve  to  explain  the  difficulty 
in  swallowing  often  noticed  in  bronchocele. 

The  isthmus  of  the  thyroid  gland  is  developed  from 
a  diverticulum  which  is  protruded  from  the  ventral 
wall  of  the  pharynx  in  the  embryo  between  the  man- 
dibular and  hyoid  parts  of  the  tongue.  The  foramen 
caecum  of  the  tongue  represents  the  spot  where  the 
diverticulum  leaves  the  pharynx.  From  this  foramen 
a  duct  (the  thyro-giossal)  may  be  found  to  lead  to 
accessory  gland  masses  about  the  hyoid  bone.  In  the 
vicinity  of  this  bone  accessory  glands  and  small  cysts 
lined  with  epithelium  are  not  infrequently  met  with. 
These  glands,  together  with  the  so-called  pyramid  or 
middle  lobe,  are  the  remains  of  the  neck  of  the  primitive 
diverticulum.  The  pyramid,  which  is  nearly  always 
connected  to  the  hyoid  bone  by  the  levator  thyroidese, 
exists    in     79    per    cent,    of    the    subjects    examined 


chap,  x.]  The    Neck.  157 

(Streckeisen).  The  lateral  lobes  are  developed  from  the 
fourth  visceral  clefts.  The  median  diverticulum  occa- 
sionally fails  to  join  one  of  the  lateral,  in  which  case  the 
isthmus  is  partially  absent.  Small  accessory  thyroid 
bodies  are  frequently  present. 

The  parathyroid  bodies  appear  to  play  an  essential 
part  in  the  function  of  the  thyroid.  They  are  of  the 
size  of  small  peas,  and  have  a  structure  similar  to  that 
of  the  suprarenal  bodies.  Two  are  usually  found  on 
each  side,  one  at  the  lower  pole  of  the  lateral  lobe,  the 
other  behind  the  lobe  amongst  the  terminal  branches  of 
the  inferior  thyroid  artery. 

Atrophy  of  the  thyroid  gland,  or  its  destruction 
by  disease,  is  apt  to  lead  to  a  general  condition  of  the 
body  known  as  myxcedema.  The  condition  closely 
resembles  cretinism,  especially  as  met  with  in  goitrous 
subjects.  Myxoedema  may  follow  the  entire  excision 
of  the  gland  by  operation,  and  has  been  produced  in 
monkeys  by  experimental  removal  of  the  same.  One 
prominent  feature  in  myxcedema  is  the  swelling  of 
the  subcutaneous  tissues  from  an  accumulation  therein 
of  a  mucinoid  substance.  "  The  probable  function 
of  the  thyroid  gland,  as  established  by  experiments 
and  clinical  observation,  concerns,  in  the  first  place, 
the  control  of  the  mucinoid  substances  in  the  tissues 
of  the  body,  and  albuminoid  metabolism  to  some  extent ; 
and  in  the  second  place,  hsemapcesis,  i.e.  manufacture 
of  blood  corpuscles  "  (Victor  Horsley). 

Vaso-motor  nerves  reach  the  thyroid  through  the 
lower  part  of  the  cervical  sympathetic  chain,  and  by  the 
same  course  nerves  pass  upwards  to  the  eye.  These 
nerves  appear  to  be  connected  centrally,  probably  in 
the  medulla,  for  in  certain  conditions  enlargement  of 
the  thyroid  is  accompanied  by  protrusion  of  the  eye 
(exophthalmic  goitre).  The  lymphatics  of  the  thyroid 
are  numerous,  and  pass  to  the  deep  cervical  and  superior 
mediastinal  lymph  glands. 

In  excision  of  the  thyroid  gland  a  Y-shaped  median 
cut  is  usually  made  that  divides  the  skin,  fascia,  platysma, 
and  auterior  jugular  veins.     The  sterno-hyoid.  sterno- 


158  Surgical    Applied   Anatomy.     [Chap.. ix. 

thyroid,  omohyoid,  and  portion  of  the  sterno-mastoid 
have  usually  to  be  divided.  The  tumour  is  carefully 
separated.  The  capsule  that  invests  the  vascular  gland 
must  not  be  torn  through.  The  thyroid  vessels  are 
ligatured  in  situ  before  the  removal  of  the  mass.  The 
superior  thyroid  meets  the  gland  at  the  apex  of  the 
lateral  lobe  and  is  there  secured.  The  inferior  thyroid 
artery  enters  the  lower  part  of  the  lobe  at  its  posterior 
aspect.  In  securing  this  vessel,  and  in  liberating  the 
lower  part  of  the  tumour,  the  recurrent  laryngeal  nerve 
is  in  great  danger  of  being  damaged.  The  thyroidea 
ima  artery  exists  in  10  per  cent,  of  all  cases. 

The  gullet  commences  opposite  the  sixth  cervical 
vertebra,  and  pierces  the  diaphragm  opposite  the  tenth 
dorsal  vertebra.  The  point  is  marked  on  the  back 
by  the  overlapping  spine  of  the  ninth  dorsal  vertebra. 
By  placing  the  stethoscope  a  little  to  the  left  of  this 
spine  fluid  may  be  heard  to  enter  the  stomach.  It 
presents  three  curves :  one  is  antero-posterior,  and 
corresponds  to  the  curve  of  the  spinal  column  ;  the 
other  two  are  lateral.  The  gullet  commencing  at  the 
middle  line  deviates  slightly  to  the  left  as  far  as  the 
root  of  the  neck ;  from  thence  to  the  fifth  dorsal 
vertebra  it  gradually  returns  to  the  middle  line,  and 
finally  it  turns  again  to  the  left,  at  the  same  time  passing 
forwards,  to  pierce  the  diaphragm.  Its  length  is  from 
9  to  10  inches.  Its  transverse  diameter  has  been  care- 
fully estimated  by  Dr.  Mouton,  by  filling  the  gullet 
with  plaster-of-Paris  in  situ,  and  then  measuring  the 
cast  thus  obtained.  Dr.  Mouton  found  that  there  were 
three  narrow  parts  in  the  gullet,  one  at  its  commence- 
ment, one  about  2f  inches  from  that  point,  and  a  third 
where  the  tube  passed  through  the  diaphragm.  The 
diameter  at  each  of  these  points  was  a  little  over  ^  an 
inch  (14  mm.) ;  the  diameter  elsewhere  was  about  f  of 
an  inch  (17  mm.  to  21  mm.).  By  forcible  distension 
the  two  upper  narrow  parts  could  be  distended  to  a 
diameter  of  18  to  19  mm.,  the  lower  part  to  25  mm., 
and  the  rest  of  the  gullet  to  a  diameter  of  nearly  1 1  inches 
(35  mm.).     It  follows  that  foreign  bodies  when  swallowed 


chr.p.  ix.]  The  Neck.  159 

are  must  apt  to  lodge  either  at  the  commence  merit 
of  the  gullet  or  at  the  spot  where  it  passes  the  diaphragm. 
The  same  parts  also  are  those  most  apt  to  show  the 
effects  of  corrosives  that  have  been  swallowed. 

Among  the  relations  of  the  oesophagus,  the  following 
may  be  noted  as  receiving  illustration  in  surgical  practice. 
The  gullet  is  in  nearly  all  its  course  in  close  relation 
with  the  front  of  the  vertebral  column.  In  the  neck 
the  trachea  is  immediately  in  front  of  it.  In  the  thorax 
it  is  in  close  connection  with  the  aorta,  and  has  the 
vena  azygos  behind  it  and  on  its  right-hand  side.  It  is, 
moreover,  partly  in  contact  with  both  pleurae,  but  more 
especially  with  the  membrane  of  the  right  side  ;  and, 
lastly,  the  recurrent  laryngeal  nerve  ascends  between  it 
and  the  trachea.   (See  Figs.  47  and  49,  pp.  353  and  361.) 

Xow,  foreign  bodies  impacted  in  the  gullet  are  very 
apt  to  lead  to  ulcerations  that  may  open  adjacent  parts. 
Thus,  in  the  Musee  Dupuytren  is  a  specimen  showing 
a  five-franc  piece  that  had  stuck  in  the  gullet,  and  had 
produced  an  ulcer  that  had  opened  the  aorta.  In 
another  instance  a  "smasher"  swallowed  a  counterfeit 
half-crown  piece.  Eight  months  afterwards  he  died  of 
haemorrhage.  The  coin  had  sloughed  into  his  aorta. 
In  another  case  (Lancet,  1871),  a  fish-bone,  lodged  in 
the  gullet  opposite  the  fourth  dorsal  vertebra,  had 
caused  two  perforating  ulcers  ;  one  on  the  right  side 
had  caused  plugging  of  the  vena  azygos  major,  while 
the  other  on  the  left  had  made  a  hole  in  the  aorta.  Less 
frequently  impacted  foreign  substances  have  found 
their  way  into  the  trachea  and  into  the  posterior 
mediastinum.  Dr.  Ogle  reports  a  case  {Path.  Soc. 
Trans.,  vol.  iv.)  where  a  piece  of  bone  impacted  in  the 
gullet  induced  ulceration  of  an  intervertebral  disc  and 
subsequent  disease  of  the  spinal  cord.  Carcinoma  of 
the  gullet,  also,  when  it  spreads,  is  apt  to  invade  adjacent 
parts,  and  especially  to  open  into  the  trachea  or  bronchi. 
If  it  spreads  to  the  pleura,  it  will  usually  involve  the 
right  pleura,  as  being  the  membrane  more  in  relation 
with  the  gullet.  Cancer  of  the  gullet  has  so  spread 
as  to  invade   the   thyroid  body,  the   pericardium,   and 


160  Surgical   Applied   Anatomy,      tckap.  ix. 

the  lung,  and  has  opened  up  the  first  intercostal  artery 
in  one  case,  and  the  right  subclavian  in  another  (Butlin's 
"  Sarcoma  and  Carcinoma,"  1882). 

The  sensory  nerve  supply  of  the  oesophagus  comes 
mainly  from  the  fifth  dorsal  segment  of  the  cord  (Head). 
In  cases  of  cancer  or  burns  of  the  gullet  pain  is  referred 
to  the  skin  of  this  segment  (see  Fig.  39,  p.  295). 

The  operation  of  flesophagotoiny  consists  in 
incising  the  gullet  for  the  purpose  of  removing  an. 
impacted  foreign  body.  The  gullet  is  usually  reached 
from  the  left  side,  since  it  projects  more  on  that  aspect. 
The  incision  is  made  between  the  sterno-mastoid  and 
the  trachea,  in  the  same  direction  as  the  incision  for 
ligaturing  the  common  carotid.  The  cut  extends 
from  the  top  of  the  thyroid  cartilage  to  the  sterno- 
clavicular joint.  The  omo-hyoid  muscle  is  drawn 
outwards,  or  cut.  The  great  vessels,  larynx  and  thyroid 
gland,  are  drawn  aside,  and  care  must  be  taken  not 
to  wound  these  structures  nor  damage  the  thyroid 
vessels,  thoracic  duct,  or  the  recurrent  nerve.  The 
gullet,  when  exposed,  is  opened  by  a  vertical  incision. 

In  oesopliagfostomy  an  opening  is  made  into 
the  gullet  through  a  like  incision  in  cases  of  stricture 
of  the  tube  high  up,  the  object  being  to  feed  the  patient 
through  the  opening  made,  in  place  of  performing 
gastrostomy.  The  risk,  however,  of  setting  up  severe 
diffuse  inflammation  in  the  loose  planes  of  connective 
tissue  deep  in  the  neck  is  very  great,  and  in  some  twenty- 
six  cases  in  which  the  operation  has  been  already  per- 
formed death  has,  in  nearly  all  instances,  supervened 
at  the  end  of  a  few  hours  or  days. 

Great  vessels. — The  course,  relations,  and  ab- 
normalities of  the  great  cervical  vessels,  together  with 
the  operations  whereby  they  may  be  ligatured,  and 
the  details  pertaining  to  those  procedures,  are  so  fully 
given,  not  only  in  works  on  operative  surgery,  but 
also  in  the  chief  anatomical  text-books,  that  nothing 
need  be  said  upon  the  matter  in  this  place.  The 
bifurcation  of  the  common  carotid  is  a  favourite  locality 
for   aneurism,    being   a   point   where   some    resistance 


chap,  ix.]  The  Neck.  r  6  i 

is  offered  to  the  blood  current.  These  tumours,  also, 
are  common  at  the  root  of  the  neck,  where  they  are 
often  due  to  extension  of  aneurysmal  disease  from  the 
aorta,  although  in  many  cases  they  have  an  independent 
origin.  It  is  in  the  neck  that  the  treatment  of  aneurism 
by  the  distal  ligature  is  most  often  carried  out.  There 
is  no  place  in  the  body  where  Brasdor's  operation  can 
be  carried  out  with  the  completeness  with  which  it 
can  be  adopted  in  the  neck.  In  this  procedure  a  main 
trunk  is  ligatured  on  the  distal  side  of  an  aneurism, 
no  branches  intervening  between  the  sac  and  the  ligature. 
The  cure  by  this  measure  depends  upon  the  fact  that 
blood  does  not  continue  to  go  to  parts  when  once  the 
need  for  blood  in  them  is  diminished.  Thus,  after 
amputation  at  the  hip  joint,  the  femoral  artery,  having 
no  need  to  carry  to  the  stump  the  amount  of  blood  it 
brought  to  the  limb,  often  shrinks  to  a  vessel  no  larger 
than  the  radial.  When  an  aneurism  low  down  in  the 
carotid  artery  is  treated  by  ligature  of  the  vessel  near 
its  bifurcation  by  Brasdor's  method,  the  blood,  having 
now,  as  it  were,  no  object  in  entering  the  carotid  trunk, 
soon  ceases  to  fill  the  vessel  entirely,  and  the  artery 
(and  in  successful  cases  the  aneurism)  shrinks  in  con- 
sequence. Wardrop's  operation,  or  the  distal  ligature 
of  large  branches  for  the  relief  of  aneurism  of  a  main 
trunk,  is  now,  perhaps,  quite  limited  as  to  its  performance 
to  the  ligature  of  the  carotid  and  subclavian  arteries 
for  innominate  aneurism.  Since  in  this  procedure 
large  branches  come  off  between  the  sac  and  the  ligature, 
it  is  not  easy  to  fully  understand  how  the  operation 
acts  beneficially.  It  is  assumed  to  owe  its  success  to 
the  same  principle  that  underlies  Brasdor's  operation. 
The  right  carotid  and  subclavian  have  also  been  ligatured 
for  aortic  aneurism  with  some  success,  and  here  also 
the  reason  for  the  good  effected  by  the  operation  is 
difficult  to  appreciate.  It  has  been  pointed  out  that 
the  innominate  artery  lies  more  or  less  directly  in  the 
axis  of  the  ascending  aorta,  while  the  left  carotid  and 
subclavian  arteries  arise  at  an  angle  to  that  axis,  and 
it  is  upon  this  fact  that  reasons  have  been  founded  for 


1 62  Surgical  Applied  Anatomy.     [Chap.  ix. 

selecting  the  vessels  of  the  right  side  (Bar well).  The 
matter  is,  however,  complicated  by  the  knowledge 
that  when  vegetations  are  swept  off  the  aortic  valves 
they  enter  the  left  carotid  with  infinitely  greater  fre- 
quency than  they  do  the  right.  The  whole  subject, 
indeed,  requires  investigation. 

The  cervical  connective  tissue  being  lax,  aneurisms 
in  this  part  can  grow  and  spread  rapidly,  and  usually 
soon  produce  "  pressure  symptoms."  As  examples  of 
these  may  be  noted  oedema  and  lividity  of  the  face  of 
the  upper  limb  from  pressure  upon  the  main  veins, 
laryngeal  symptoms  from  pressure  upon  the  recurrent 
nerve  or  trachea,  spasm  of  the  diaphragm  from  pres- 
sure upon  the  phrenic  nerve,  damage  to  the  sympa- 
thetic, and  giddiness  and  impaired  vision  from  anaemia 
of  the  brain. 

The  vertebral  artery  has  been  ligatured  with  doubt- 
ful benefit  in  cases  of  epilepsy.  It  is  surrounded  by 
vasomotor  nerves  derived  from  the  inferior  cervical 
ganglion,  which  also  are  necessarily  tied.  The  artery 
is  reached-  through  an  incision  made  along  the  posterior 
border  of  the  sterno-mastoid  muscle  just  above  the 
clavicle.  The  "  carotid  tubercle  "  {see  page  136)  is  then 
sought  for,  and  vertically  below  it  lies  the  artery  in  the 
gap  between  the  scalenus  anticus  and  longus  colli 
muscles.  The  procedure  is  surrounded  with  considerable 
difficulties. 

Dr.  Bright  and  Dr.  Bamskill  have  stated  that  dis- 
ease involving  the  vertebral  artery  just  before  it  enters 
the  skull  may  lead  to  pain  at  the  back  of  the  head.  It 
is  well  known  that  the  suboccipital  nerve  lies  in  close 
connection  with  the  artery  over  the  posterior  arch  of  the 
atlas,  and  that  it  gives  a  branch  to  the  great  occipital 
nerve  which  is  distributed  to  the  back  of  the  head. 
The  close  connection  of  artery  and  nerve  and  this  com- 
municating branch  may  serve  to  explain  the  symptom 
noted.  In  some  of  Dr.  RamskiU's  cases  there  was 
difficulty  of  articulation.  This  he  ascribes  to  pressure 
upon  the  hypoglossal  nerve,  which  is  also  in  close  relation 
with    the    vertebral    artery.     The    innominate    artery 


chap,  ix.]  The  Neck.  163 

has  been  temporarily  compressed  through  an  incision 
made  in  the  median  line  near  to  the  vessel.  The  posterior 
aspect  of  the  artery  is  exposed  and  compressed  by  the 
finger  against  the  sterno-clavicular  articulation. 

In  cases  of  bleeding  from  branches  of  the  external 
carotid  it  is  better,  when  possible,  to  ligature  the  trunk 
of  that  vessel  in  preference  to  securing  the  common 
carotid.  The  latter  procedure  has  a  high  death  rate 
(50  per  cent.),  due  (1)  to  brain  mischief,  following  the 
lessened  blood  stream  through  the  internal  carotid,  and 
(2)  to  secondary  haemorrhage,  due  to  the  very  free 
anastomosing  channels. 

Air  in  veins. — The  veins  of  the  neck  are  under 
the  influence  of  the  respiratory  movements.  The 
veins  do  not  collapse  owing  to  attachments  to  the 
surrounding  fasciae.  During  inspiration  these  vessels 
become  more  or  less  emptied ;  during  expiration 
they  become  enlarged  and  turgid.  With  greatly  im- 
peded breathing  they  may  attain  formidable  size. 
Since  ether  usually  causes  some  respiratory  difficulty, 
it  is  seldom  administered  in  operations  on  the  neck. 
The  only  other  veins  that  are  under  the  influence  of  the 
aspiratory  power  of  the  thorax  are  the  axillary  vein 
and  its  larger  tributaries.  When  any  one  of  these  vessels 
is  wounded,  and  the  wound  is  for  the  moment  dry,  air 
may  very  readily  be  drawn  into  it  during  the  inspiratory 
act,  just  as  air  is  drawn  into  the  trachea.  The  air  causes 
embolism  of  the  pulmonary  capillaries. 

The  lymphatic  glands  of  the  head  and 
neck  are  numerous,  and  arranged  in  the  following  sets 
(Fig.  21)  :- 

(1)  Submaxillary  glands,  10  to  15  in  number,  situated 
at  the  lower  border  of  the  jaw  beneath  the  cervical  fascia  ; 
(2)  the  supra-hyoid,  1  or  2  in  number,  situated  between 
the  chin  and  hyoid  bone  near  the  middle  line  ;  (.3)  paro- 
tid or  pre-auricular  set,  situated  in  and  over  the  parotid 
gland  ;  (4)  post-auriciilar,  or  mastoid,  2  to  4  in  number, 
situated  over  the  mastoid  process  ;  (5)  occipital,  3  to  5 
in  number,  over  the  insertion  of  the  complexus  muscle  ; 
(6)  superficial   cervical   glands,    often   absent,   situated 


164 


Surgical  Applied  Anatomy.     [Chap.  ix. 


over  the  sterno-mastoid  along  the  external  jugular  vein  ; 
(7)  laryngeal,  1  to  3  in  number,  below  the  great  horn 


Fig.  21. — Showing  the  position  of  the  Lymphatic  Glands  of  the  Head  and 
Neck.  The  outlines  of  the  sterno-mastoid  (s.M.)  trapezius  (trai\), 
internal  jugular,  subclavian,  and  right  innominat    veins  are  shown. 

l,  Submaxillary  glands,  1'  area  drained  ;  2,  suprahyoid  elands,  2'  aren  drained  : 
3,  parotid  glands, : V  area  drained ;  4,  post  auricular  glands,  4'  area  drained  ; 
5,  occipital  glands,  5'  area  drained;  6,  in  front  of  external  jugular  vein, 
marking  position  of  the  superficial  cervical  glands  ;  7,  laryngeal  gland  ;  8,  8,  8, 
upper  deep  cervical  glands;  9,9,9,  lower  deep  cervical  glands:  10,  gland 
receiving  lymph  from  thyroid  ;  ll,  superior  mediastinal  glands:  12,  axillary 
glands. 


Chap,  ix.]  The  Neck.  165 

of  the  hyoid  ;  (8)  the  upper  deep  cervical  set,  10  to  20 
in  number,  .situated  over  the  upper  part  of  the  internal 
jugular  vein  and  bifurcation  of  the  common  carotid 
artery  ;  (9)  lower  deep  cervical  set,  surrounding  the 
terminal  parts  of  the  internal  jugular,  subclavian,  external 
jugular,  and  transverse  cervical  veins.  This  set  becomes 
continuous  with  the  axillary  and  mediastinal  glands. 

These  glands  are  very  often  enlarged  and  inflamed, 
and  it  is  in  this  part  of  the  lymphatic  system  that  the 
changes  in  scrofula  arc  most  commonly  met  with.  The 
inflammatory  affections  in  glands  would  appear  to  be 
always  of  a  secondary  nature  (if  we  exclude  some  cases 
of  inflammation  incited  by  injury,  and  perhaps  by  ex- 
posure to  severe  cold),  and  to  follow  disturbances  in  those 
parts  of  the  periphery  whence  they  respectively  receive 
their  lymph.  It  may  be  convenient,  therefore,  to  group 
the  relations  of  certain  glands  to  certain  parts  of  the 
periphery. 

Scalp. — Posterior  part  =  occipital  and  post-auricular 
glands.  Frontal  and  parietal  portions  =  parotid  glands 
(Fig.  21). 

Vessels  from  the  scalp  also  enter  the  superficial 
cervical  set  of  glands. 

Skin  of  face  and  neck  =  submaxillary,  parotid, 
and  superficial  cervical  glands. 

External  ear  =  superficial  cervical  glands. 

Lower  lip  =  submaxillary  and  suprahyoid  glands. 

Buccal  cavity  =  submaxillary  glands  and  deep 
cervical  glands  (upper  set). 

Gums  of  lower  jaw  =  submaxillary  glands. 

Tongue.—  Anterior  portion  =  suprahyoid  and  sub- 
maxillary glands.  Posterior  portion  =  deep  cervical 
glands  (upper  set). 

Tonsils  and  palate  =  deep  cervical  glands  (upper  set). 

Pharynx. — Upper  part  =  parotid  and  retro- pha- 
ryngeal  glands.  Lower  part  =  deep  cervical  glands 
(upper  set). 

Larynx,  orbit,  and  roof  of  mouth  —  deep  cervical 
glands  (upper  set). 

Nasal  fossce  =  retro-pharyngeal  glands,  deep  cervical 


1 66  Surgical  Applied  Anatomy.     [Chap.  ix. 

glands  (upper  set).  Some  lymphatics  from  the  posterior 
part  of  the  fossae  enter  the  parotid  glands.* 

In  the  removal  of  the  deep  cervical  glands  a  number 
of  structures  are  liable  to  be  wounded.  The  glands 
frequently  become  firmly  adherent  to  the  internal 
jugular  vein ;  the  uppermost  glands  surround  the 
spinal  accessory  nerve  ;  the  superficial  cervical  nerves 
pass  among  those  of  the  lower  deep  cervical  set ;  the 
thoracic  duct  has  been  wounded  in  removing  glands 
from  the  left  supra-clavicular  fossa. 

Branchial  fistiilae — Certain  congenital  fistulas 
are  sometimes  met  with  in  the  neck,  which  are  due  to 
partial  persistence  of  one  of  the  branchial  clefts.  These 
clefts  are  placed  in  the  foetus  between  the  branchial 
arches.  The  arches  are  usually  described  as  five  in 
number.  The  first  lays  the  foundation  for  the  lower 
jaw  and  malleus.  From  the  second  are  developed  the 
incus,  the  styloid  process,  the  stylo-hyoid  ligament,  and 
lesser  cornu  of  the  hyoid  bone.  From  the  third  is  formed 
the  body  and  greater  cornu  of  the  hyoid  bone,  while  the 
fourth  and  fifth  take  part  in  the  formation  of  the  soft 
parts  of  the  neck  below  the  hyoid  bone.  The  first  cleft 
is  between  the  first  and  second  arches.  "  The  cervical 
branchial  fistulas  appear  congenitally  as  very  fine  canals 
opening  into  minute  orifices  in  one  or  both  sides  of  the 
fore  part  of  the  neck,  and  leading  backwards  and  in- 
wards or  backwards  and  upwards  towards  the  pharynx 
or  oesophagus  "  (Paget).  Their  length  is  about  \\  to 
2^-  inches,  and  their  diameter  varies  from  that  of  a 
bristle  to  that  of  an  ordinary  probe.  They  usually 
exist  about  the  line  of  the  third  or  fourth  cleft,  and  are 
most  often  met  with  just  above  the  sterno-clavicular 
joint.  Others  are  found  about  the  level  of  the  top 
of  the  thyroid  cartilage  at  the  anterior  edge  of  the  sterno- 
mastoid  muscle.  About  some  of  these  fistuhe,  or  in 
spots  where  they  commonly  open,  flat  pieces  of  cartilage 
may  be  found.  The  more  prominent  of  these  have  been 
termed  supernumerary  auricles.  Certain  dermoid  cysts 
of  the  neck  arise  from  unobliterated  branchial  spaces, 

*  From  "Scrofula,  and  its  Gland  Diseases,"  by  the  Author. 


Chap,  ix.]  The  Neck.  167 

and  it  would  appear  also  that  certain  polycystic  con- 
genital tumours,  occurring  as  one  form  of  "  hydrocele 
of  the  neck,"'  may  be  developed  from  an  imperfectly 
closed  cleft.  1  have  elsewhere  detailed  the  dissection 
of  one  of  these  tumours  that  appeared  to  be  associated 
with  a  partially  closed  second  branchial  cleft  (Path.  Soc. 
Trans.,  1881). 

His  has  shown  that  many  branchial  fistuke  and 
cysts  are  formed  from  the  cervical  sinus.  The  cervical 
sinus  is  produced  in  the  neck  of  the  embryo  by  a  rapid 
growth  in  the  second  and  third  arches  which  causes  them 
to  grow  backwards  and  overlap  the  fourth  and  fifth. 
The  piece  of  epi'blast  thus  included  in  the  neck  usually 
disappears,  but  it  may  persist  and  give  rise  to  a  cyst 
or,  if  open,  to  a  fistula.  It  is  to  be  remembered  that  the 
branchial  clefts  are  only  depressions  in  the  wall  of  the 
pharynx,  not  complete  fissures.  Hence  fistuke  rarely 
communicate  with  the  pharynx 


i68 


$art  ih 

CHAPTER     X. 

THE    THOEAX. 

1.  The  thoracic  walls. — The  two  sides  of  the 
chest  are  seldom  symmetrical,  the  circumference  of 
the  right  side  being  usually  the  greater,  a  fact  that  is 
supposed  to  be  explained  by  the  unequal  use  of  the 
upper  limbs.  In  Pott's  disease,  involving  the  dorsal 
region,  when  the  spine  is  much  bent  forwards,  the 
thorax  becomes  greatly  deformed.  Its  antero-posterior 
diameter  is  increased,  the  sternum  protrudes,  and  may 
even  be  bent  by  the  bending  of  the  spine,  the  ribs  are 
crushed  together,  and  the  body  may  be  so  shortened 
that  the  lower  ribs  overlap  the  iliac  crest. 

In  pigeon -breast  deformity  the  sternum  and 
cartilages  are  rendered  protuberant,  so  that  the  antero- 
posterior measurement  of  the  chest  is  much  increased, 
while  a  deep  sulcus  exists  on  either  side  along  the  line; 
of  junction  of  the  ribs  and  their  cartilages.  It  is  by 
the  sinking  in  of  the  parietes  along  this  line  that  the 
protuberance  is  produced.  Shaw  gives  the  following 
explanation  of  this  deformity  :  "  When  an  inspiration 
is  taken,  a  threatened  vacuum  is  created  within  the 
chest,  air  rushes  in  by  atmospheric  pressure,  and  at  the 
end  of  the  inspiration  the  balance  of  pressure  without 
the  chest  and  within  it  are  equalised.  If  in  inspiration 
there  is  an  impediment  to  the  entrance  of  air,  the  atmo- 
spheric pressure  upon  the  external  wall  of  the  chest 
must  produce  some  effect,  being  unbalanced  by  a  like 
pressure  upon  the  inner  chest  wall.  In  children,  and 
especially  in  rickety  children,  the  thorax  is  very  pliable 


chap.'x.]  The  Thorax.  169 

and  elastic,  and  if  a  constant  impediment  exists  to  the 
entrance  of  air,  as  afforded,  for  example,  by  the  greatly 
enlarged  tonsils,  the  thoracic  walls  may  yield  in  time 
to  the  unbalanced  pressure  brought  to  bear  upon  them 
at  each  inspiration.  The  weakest  part  of  the  thorax 
is  along  the  costo-chondral  line  on  either  side,  and  it  is 
here  that  the  parietes  yield  most  conspicuously  in  such 
cases,  and  by  this  yielding  the  deformity  is  produced." 

Deformities  of  the  chest  result  from  abnormal 
curvatures  of  the  dorsal  part  of  the  spinal  column.  The 
ribs  are  firmly  bound  to  the  vertebras  by  the  costo- 
vertebral and  costo-trans verse  ligaments,  and  hence 
alteration  in  the  position  of  vertebras  is  attended  by 
changes  in  the  costal  series.  When  the  spinal  muscles 
are  no  longer  able  to  keep  the  vertebras  firmly  erect, 
the  spinal  column  yields  under  the  weight  of  the  upper 
half  of  the  body.  In  scoliosis  of  the  spine  not  only  is  a 
lateral  curvature  formed,  but  the  vertebras  undergo  a 
rotation  at  the  same  time.  The  vertebral  bodies  move 
towards  the  convexity  and  their  spines  towards  the 
concavity  of  the  curvature  (Fig.  22).  The  ribs  on  the 
concave  side  are  carried  forwards  on  the  transverse 
processes  and  their  angles  open  out,  the  side  of  the 
chest  becoming  flattened  behind.  On  the  other  side 
(convex)  the  angles  are  unduly  prominent,  for  the  ribs 
are  carried  backwards  at  their  vertebral  extremities 
and  bent  inwards  in  front.  The  transverse  diameter 
of  the  chest  thus  becomes  oblique  (Fig.  22).  On  the 
concave  side  the  intercostal  spaces  are  diminished  in 
size,  the  ribs  even  coming  into  contact,  while  on  the 
convex  side  the  spaces  are  increased  in  size.  The  thoracic 
viscera  are  necessarily  distorted  in  shape  and  altered 
in  position. 

The  sternum. — The  upper  edge  of  the  sternum 
corresponds  to  the  disc  between  the  second  and  third 
dorsal  vertebrae,  and  the  sterno-xiphoid  joint  to  the 
middle  of  the  ninth  dorsal.  In  the  foetus  at  full  term 
the  upper  edge  of  the  sternum  is  opposite  the  middle 
of  the  first  dorsal  vertebra  (Symington).  A  trans- 
verse ridge  may  be  felt  upon  its  anterior  surface  that. 


I7° 


Surgical  Applied  Anatomy.       [Chap,  x. 


corresponds  to  the  junction  of  the  manubrium  and 
gladiolus,  and  is  in  a  line  with  the  second  costal 
cartilages.  The  skin  over  the  sternal  region  is  the 
part  of  the  surface  most  frequently  the  seat  of  keloid. 
The  bone  is  rarely  fractured^  being  soft  and  spongy, 
and  supported  by  the  elastic  ribs  and  their  cartilages, 
as  by  a  series  of  springs.     In  the  old,  when  the  cartilages 


r  d 


A.R  0 


Fig.  22. — Showing  the  changes  in  the  Thorax  which  follow  Scoliosis  of 
the  Spine.     (After  Redard.) 

a.p.d.,  An  tern-posterior  axis   of   the  vertebra ;    t.d.,  transverse    diameter  of 
the  chest:  s.,  sternum. 


are  ossified  and  the  chest  more  rigid,  the  tendency  to 
fracture  is  increased.  The  sternum  is  most  often  found 
fractured  in  connection  with  injuries  to  the  spine, 
although  it  may  be  broken  by  simple  direct  violence. 
The  bone  may  be  fractured  by  violent  bending  of  the 
spine  backwards,  and  by  abrupt  bending  of  it  forwards. 
In  the  former  instance  the  lesion  is  probably  due  to 
muscular  violence,  to  the  abdominal  muscles  and  the 
sterno-mastoid  pulling  one  against  the  other.  In  the 
latter  instance  the  lesion  is  commonly  brought  about 
by  the  violent  contact  of  the  chin  with  the  bone.  In 
all   instances   the   fracture   is   usuallv   transverse,   and 


Chap,  x.]  The   Thorax.  T71 

most  often  occupies  the  line  between  the  manubrium 
and  the  gladiolus.  As  these  two  parts  of  the  bone  are 
not  entirely  united  until  middle  life,  and  are  often  not 
united  at  all,  it  follows  that  the  lesion  is  in  many  cases 
a  dislocation  rather  than  a  fracture.  The  manubrium 
in  these  injuries  generally  remains  in  situ,  while  the 
gladiolus  with  the  ribs  is  displaced  forwards  in  front  of 
it.  Malgaigne  cites  the  case  of  a  youth  who,  from 
constant  bending  at  his  work  as  a  watchmaker,  caused 
the  second  piece  of  the  sternum  to  glide  backwards 
behind  the  manubrium.  Here,  probably,  the  connection 
between  the  two  bones  was  not  very  substantial. 

From  its  exposed  position  and  cancellous  structure, 
the  sternum  is  liable  to  many  affections,  such  as  caries 
and  gummatous  periostitis.  The  comparative  softness 
also  of  the  bone  is  such  that  it  has  been  penetrated  by 
a  knife  in  homicidal  wounds.  The  shape  and  position 
of  the  bone  have  also  been  altered  by  pressure,  as  seen 
sometimes  in  artisans  following  employments  requiring 
instruments,  etc.,  to  be  pressed  against  the  chest. 

Certain  holes  may  appear  in  the  middle  of  the 
sternum,  and  through  them  mediastinal  abscesses  may 
escape,  and  surface  abscesses  pass  deeply  into  the  thorax. 
These  holes  result  from  imperfect  union  of  the  right 
and  left  sternal  bars,  out  of  which  the  sternum  is  formed. 
In  the  case  of  E.  Groux,  the  bone  was  separated  ver- 
tically into  two  parts.  The  gap  could  be  opened  by 
muscular  effort  and  the  heart  exposed,  covered  only 
by  the  soft  parts.  The  sternum  has  been  trephined 
for  mediastinal  abscess,  and  for  paracentesis  in  peri- 
cardial effusion,  and  it  has  been  proposed  also  to  ligature 
the  innominate  artery  through  a  trephine  hole  in  the 
upper  part  of  the  bone. 

The  ribs  are  placed  so  obliquely  that  the  anterior 
end  of  one  rib  is  on  a  level  with  the  posterior  end  of 
a  rib  some  way  below  it  in  numerical  order.  Thus 
the  first  rib  in  front  corresponds  to  the  fourth  rib 
behind,  the  second  to  the  sixth,  the  third  to  the  seventh, 
the  fourth  to  the  eighth,  the  fifth  to  the  ninth,  the  sixth 
to  the  tenth,  and  the  seventh   to    the    eleventh.      If   a 


172  Surgical  Apt  lied  Anatomy.       [Chap.  x. 

horizontal  line  be  drawn  round  the  body  at  the  level  of 
the  inferior  angle  of  the  scapula,  Avhile  the  arms  are  at 
the  side,  the  line  would  cut  the  sternum  in  front  at  the 
attachment  of  the  sixth  cartilage,  would  cut  the  fifth 
rib  at  the  nipple  line,  and  the  eighth  rib  at  the  vertebral 
column.  The  second  rib  is  indicated  by  the  transverse 
ridge  on  the  sternum  already  alluded  to.  The  lower 
border  of  the  pectoralis  major  leads  to  the  fifth  rib,  and 
the  first  visible  serration  of  the  serratus  magnus  cor- 
responds to  the  sixth.  The  longest  rib  is  the  seventh, 
the  shortest  the  first.  In  breadth  the  bones  decrease 
from  the  first  to  the  twelfth.  The  most  oblique  rib  is 
the  ninth. 

The  ribs  are  elastic  and  much  curved,  and,  being 
attached  by  many  ligaments  behind  to  the  column, 
and  in  front  to  the  yielding  cartilages,  resist  injuries 
tending  to  produce  fracture  with  the  qualities  possessed 
by  a  spring.  A  rib  may  be  fractured  by  indirect  violence, 
as  by  a  wheel  passing  over  the  body  when  lying  prostrate 
on  the  back.  In  such  a  case  the  force  tends  to  approxi- 
mate the  two  ends  of  the  bone,  and  to  increase  its  curve. 
When  it  breaks,  therefore,  it  breaks  at  the  summit  of 
its  principal  curve,  i.e.  about  the  centre  of  the  bone. 
The  fragments  fracture  outwards,  and  the  pleura  stands 
no  risk  of  being  penetrated.  When  the  rib  is  broken 
by  direct  violence,  lesion  occurs  at  the  spot  encountered 
by  the  force,  the  bone  fractures  inwards,  the  curve 
of  the  rib  tends  to  be  diminished  rather  than  increased, 
and  there  is  much  risk  of  the  fragments  lacerating 
the  pleura. 

Those  most  often  broken  are  the  sixth,  seventh, 
and  eighth,  they  being  under  ordinary  circumstances 
the  most  exposed.  The  rib  least  frequently  fractured 
is  the  first,  which  lies  under  cover  of  the  clavicle. 
Fractures  are  more  common  in  the  elderly  than  in 
children,  owing  to  the  ossification  of  the  cartilages 
that  takes  place  in  advancing  life.  When  a  rib  is 
fractured,  no  shortening  occurs,  the  bone  being  fixed 
both  in  front  and  behind,  while  vertical  displacement 
is    prevented    by   the   attachments   of    the    intercostal 


Chap,  x.]  The  Thorax.  173 

muscles.  Thus  no  obvious  deformity  is  produced  unless 
a  number  of  consecutive  ribs  are  the  subjects  of  frac- 
ture. These  bones  have  been  broken  by  muscular  vio- 
lence, as  during  coughing,  and  in  violent  expulsive 
efforts  such  as  are  incident  to  labour.  In  such  instances 
the  ribs  are  probably  weakened  by  atrophy  or  disease. 

In  many  instances  of  gun-shot  wound  the  curve 
of  the  rib  has  saved  the  patient's  life.  In  such  cases 
the  bullet  has  entered  behind  near  the  dorsal  spine, 
has  been  conducted  round  the  chest,  along  the  curve 
of  a  rib  beneath  the  skin,  and  has  escaped  again  near 
the  sternum.  This  property,  however,  of  the  ribs  for 
turning  bullets  refers  rather  to  the  days  of  round  bullets, 
and  not  to  modern  conical  projectiles. 

In  rickets  changes  take  place  at  the  point  of 
junction  of  the  ribs  and  cartilages  leading  to  bony 
elevations,  which  produce,  when  the  ribs  on  both  sides 
are  affected,  the  condition  known  as  the  "  rickety  rosary." 

The  intercostal  spaces  are  wider  in  front 
than  behind,  and  between  the  upper  than  the  lower 
ribs.  The  widest  of  the  spaces  is  the  third,  then  the 
second,  then  the  first.  The  narrowest  spaces  are  the 
last  four.  The  first  five  spaces  are  wide  enough  to 
admit  the  whole  breadth  of  the  index  finger.  The 
spaces  are  widened  in  inspiration,  narrowed  in  expiration, 
and  can  be  increased  in  width  by  bending  the  body 
over  to  the  opposite  side. 

Paracentesis  is  usually  performed  in  the  sixth 
or  seventh  space,  at  a  point  midway  between  the  sternum 
and  the  spine,  or  midway  between  the  anterior  and 
posterior  axillary  lines.  If  a  lower  space  be  selected 
there  is  danger  of  wounding  the  diaphragm,  especially 
upon  the  right  side.  If  the  eighth  or  ninth  space  is 
selected  the  incision  is  made  just  external  to  the  line 
of  the  angle  of  the  scapula.  The  trochar  should  be 
entered  during  inspiration,  the  space  being  widened 
thereby,  and  should  be  kept  as  near  as  possible  to  the 
lower  border  of  the  space,  so  as  to  avoid  the  intercostal 
vessels.  Tapping  of  the  chest  through  any  space 
posterior  to  the  angles  of  the  ribs  is  not  practicable, 


174  Surgical  Applied  Anatomy.      [Chap.  x. 

owing  to  the  thick  covering  of  muscles  upon  the  thoracic 
Wall  m  this  place,  and  the  fact  that  the  intercostal  artery, 
having  a  more  horizontal  course  than  the  corresponding 
ribs,  crosses  the  middle  of  this  part  of  the  space  obliquely. 
Beyond  the  angle  the  intercostal  vessels  lie  in  a  groove 
on  the  inferior  border  of  the  rib  forming  the  upper 
boundary  of  the  space.  The  vein  lies  immediately 
above  the  artery,  and  the  nerve  immediately  below 
it.  In  the  Upper  four  or  five  spaces,  however,  the  nerve 
is  at  first  higher  than  the  artery. 

Owing  to  the  protection  it  derives  from  the  ribs 
and  the  intercostal  muscles,  it  happens  that  the  inter- 
costal artery  is  seldom  wounded,  and  when  wounded 
it  will  be  understood  that  considerable  difficulty  is 
experienced  in  securing  the  vessel  without  doing  damage 
to  the  pleura  and  adjacent  parts. 

Pus  may  readily  be  conducted  along  the  loose  tissue 
between  the  two  layers  of  intercostal  muscles.  Thus, 
in  suppuration  following  upon  disease  of  the  vertebrae, 
or  of  the  posterior  parts  of  the  ribs,  the  pus  may  be 
conducted  along  the  intercostal  spaces  to  the  sternum, 
and  may  thus  present  at  a  considerable  distance  from 
the  real  seat  of  the  disease. 

Removal  of  ribs. — In  order  to  obtain  a  free 
opening  into  the  pleural  cavity  a  portion  of  one  or  even 
two  ribs  may  be  excised. 

In  some  cases  of  long-standing  empyema  with  open 
sinus  all  that  part  of  the  bony  wall  of  the  thorax  which 
corresponds  to  the  outer  boundary  of  the  suppurating 
cavity  is  removed  in  order  that  the  cavity  may  collapse 
and  be  in  a  position  to  close.  This  latter  measure  is 
known  as  Estlander's  operation,  or  thoracoplasty.  In 
some  instances  portions  of  as  many  as  nine  ribs  have 
been  excised,  and  the  total  length  of  bone  removed 
has  reached  50  to  60  inches. 

In  removing  a  rib  the  bone  is  entirely  bared  of 
periosteum  with  the  rugine,  and  the  excision  is  extra- 
periosteal.  Imthis  way  the  intercostal  vessels  are  not 
exposed,  and,  if  divided  subsequently,  can  be  readily 
secured  when  the  ribs  are  out  of  the  way. 


Chap,  x.]  The  Thorax.  175 

The  internal  mammary  artery  runs  parallel 
to  trie  border  of  the  sternum,  and  about  h  an  inch  from 
it.  It  may  give  rise  to  rapidly  fatal  haemorrhage  if 
wounded.  The  vessel  may  readily  be  secured _  in  the 
first  three  intercostal  spaces,  and  with  some  difficulty 
in  the  fourth  or  fifth  space.  It  is  most  easily  reached 
through  the  second  space,  and  cannot  be  secured  through 
any  space  below  the  fifth. 

The  female  breast  extends  from  the  second 
rib  above  to  the  sixth  below,  and  from  the  side  of  the 
sternum  to  the  mid-axillary  line  (Stiles).  In  cases  of 
retained  lactation  the  twelve  to  fifteen  irregular  lobes 
which  make  up  the  body  of  the  gland  can  be  felt  radiating 
outwards  from  the  nipple.  The  lactiferous  ducts, 
which  correspond  in  number  to  the  lobes,  open  at  the 
apex  of  the  nipple,  within  which  each  shows  a  dilata- 
tion or  ampulla.  Branching  processes  of  adjoining 
lobes  unite  and  enclose  spaces  within  the  body  of  the 
gland,  containing  connective  tissue  and  masses  of  fat. 
After  the  menopause,  when  the  glandular  tissue  is 
absorbed  in  great  part,  and  during  the  resting  con- 
dition, fat  forms  the  greater  part  of  the  female  breast, 
Besides  the  main  body  of  the  gland.  Stiles  has  drawn 
attention  to  numerous  peripheral  processes  which  lie 
in  the  surrounding  connective  tissue. 

Although  the  principal  part  of  the  breast  rests  on 
the  pectoralis  major,  quite  one-third  of  the  gland 
crosses  the  outer  border  and  rests  on  the  serratus 
magnus  within  the  axilla.  It  also  covers  the  origins 
of  the  obliquus  abdominis  externus  and  rectus  abdominis. 
In  excision  or  inflammation  of  the  breast  it  is  important 
to  bind  the  arm  by  the  side  to  keep  the  parts  from  being 
disturbed  by  the  pectoralis  major.  Peripheral  processes 
of  the  gland  and  many  of  its  deep  lymphatics  enter 
the  pectoral  sheath,  hence  the  removal  of  this 
structure,  and  even  part  of  the  muscle,  if  complete 
extirpation  of  cancer  is  to  be  assured.  The  loose  retro- 
mammary tissue  which  binds  the  mamma  loosely  to 
the  pectoral  sheath  may  be  the  seat  of  abscess,  or  some- 
times of  a  bursal  cyst. 


176  Surgical  Applied  Anatomy.       [Chap.  x. 

The  nipple  is  situated  on  the  fourth  intercostal 
space,  about  §  of  an  inch  from  the  junction  of  the  ribs 
with  their  cartilages.  It  contains  erectile  and  muscular 
tissue,  and  is  richly  supplied  by  cutaneous  branches 
of  the  third  and  fourth  spinal  nerves.  The  skin  is 
pigmented,  thin  and  sensitive,  and  often  the  seat  of 
painful  fissures  and  excoriations.  In  painful  diseases 
of  the  breast,  tender  areas  occur  over  the  fourth 
and  fifth  spinal  segments  (Fig.  39,  p.  295)  (Head). 

The  breast  is  developed  by  a  solid  invagination  of 
epiblast  at  the  point  afterwards  marked  by  the  nipple. 
About  the  sixth  month  of  fcetal  life  the  primitive 
mammary  bud  branches  out  in  all  directions  within 
the  subcutaneous  tissue.  Thus  it  comes  about  that 
the  subcutaneous  fascia  is  condensed  around  the  gland, 
forming  its  capsule.  The  retro-mammary  part  of  the 
capsule  is  connected  at  the  interlobular  spaces  with 
the  superficial  layer,  which  in  turn  is  fixed  to  the  skin 
by  subcutaneous  bands,  or  skin  ligaments. 

It  is  through  lymph  channels  that  cancer  spreads, 
and  those  of  the  breast,  which  is  one  of  the  commonest 
sites  of  cancer,  are  of  especial  importance  if  complete 
eradication  of  the  disease  is  to  be  obtained.  The  lymph 
vessels  are  arranged  in  the  following  sets  :  (1)  Peri- 
lobular, round  the  acini  and  lobules  ;  (2)  periductal, 
round  the  lactiferous  ducts  ;  (3)  interlobar,  situated 
in  the  interlobar  septa  and  joining  (4)  the  retro- 
mammary network  with  (5)  the  superficial  mammary 
in  the  anterior  part  of  the  capsule.  If  the  interlobar 
septa  are  invaded  by  cancer  they  contract,  and  through 
their  cutaneous  attachments  cause  depressions  in  the 
skin  ;  if  the  process  invades  the  periductal  vessels,  the 
nipple  is  retracted.  The  mammary  lymphatic  system  is 
connected  with  the  subcutaneous  network  of  vessels,  to 
which  cancer  may  spread,  producing  that  variety  of 
the  disease  known  as  cancer  en  cuirasse.  Through 
communications  with  the  lymph  channels  of  the  pectoral 
fascia  and  muscle,  cancer  of  the  breast  may  spread  to 
these  structures.  The  gland  then  becomes  firmly 
fixed  to  the  deeply  seated  structures.     The  great  bulk 


chap,  x.j  The  Thoraa.  177 

of  the  lymph  vessels  pass  from  the  breast  to  the 
pectoral  glands,  six  to  eight  in  number,  situated  along 
the  anterior  border  of  the  axilla,  and  to  the  central 
axillary  set,  twelve  to  fifteen  in  number,  situated 
beneath  the  axillary  tuft  of  hair  and  on  the  inner 
side  of  the  axillary  vein.  From  these  two  sets  the 
lymph  vessels  pass  to  the  deep  axillary  glands  lying 
along  the  front  and  inner  side  of  the  axillary  vessels. 
The  deep  axillary  glands  become  continuous  with  the 
lower  deep  cervical  glands.  It  is  mainly  along  this  path 
that  cancer  tends  to  spread,  but  vessels  leave  the  inner 
segment  of  the  breast  and  pass  to  the  anterior  inter- 
costal glands  situated  in  the  upper  four  intercostal 
spaces  and  lying  on  each  side  of  the  internal  mammary 
vessels,  while  occasionally  a  few  vessels  pjass  to  the 
cephalic  gland  situated  in  the  hiatus  between  the  deltoid 
and  pectoralis  major  muscles.  When  the  normal 
channels  become  clogged  with  cancerous  emboli  the 
lymph  passes  by  circuitous  paths.  The  subscapidar 
glands,  surrounding  the  subscapular  vessels  on  the 
posterior  wall  of  the  axilla,  may  become  infiltrated  ; 
through  the  lymphatics  of  the  arm,  which  end  in  the 
central  axillary  glands,  the  structures  round  the  shoulder 
may  become  the  seats  of  secondary  deposit,  and  through 
the  communication  between  the  lymph  system  of  one 
breast  with  that  of  the  other,  across  the  sternum,  a 
secondary  deposit  may  even  occur  in  the  opposite  breast 
(Stiles). 

The  breast  is  thinnest  along  a  line  drawn  from  the 
sterno-clavicular  joint  to  the  nipple.  Abscesses  situated 
beneath  the  breast  not  unfrequently  make  their  way 
through  the  gland  at  some  point  along  this  line. 
Abscesses  of  the  breast  should  be  opened  by  incisions 
radiating  from  the  nipple,  to  avoid  wounding  the 
lactiferous  ducts. 

The  intercosto-humeral  nerve  pierces  the  central 
set  of  axillary  glands.  It  becomes  compressed  when 
these  glands  are  invaded  by  cancer,  and  pain  is  referred 
to  the  termination  of  the  nerve  over  the  posterior  aspect 
of  the   arm  above   the   elbow.     Various   parts   of  the 


178  Surgical  Applied  Anatomy.       [Chap. x. 

brachial  plexus  may  also  become  involved  or  the  axillary 
vein  or  lymphatics  occluded,  the  arm  being  swollen 
and  cedematous  in  consequence. 

The  following  groups  of  arteries  supply  the  gland 
and  are  cut  in  excision  of  the  organ:  (1)  The  long 
thoracic,  alar  thoracic,  thoracic  branches  of  the  acromio- 
thoracic  axis  ;  (2)  anterior  perforating  branches  from 
the  internal  mammary  at  the  second,  third,  and  fourth 
intercostal  spaces  ;  (3)  lateral  branches  from  the  second, 
third,  and  fourth  intercostal  arteries. 

Supernumerary  nipples  and  breasts  may  occur. 
They  are  commonly  found  in  a  line  between  the  axilla 
and  the  groin.  In  the  embryonic  stage  of  all  mammals 
an  epiblastic  mammary  ridge  is  found  in  this  position. 
In  man  it  disappears  except  at  one  point,  but  occasionally 
some  isolated  part  may  persist  and-  proceed  to  form  a 
breast.  Embryology  fails  to  explain  the  occurrence  of 
breasts  on  the  buttock  or  back,  where  they  are 
occasionally  found. 

2.  The  thoracic  viscera. 

The  Jung. — The  apex  of  the  lung  rises  in  the  neck 
from  1  to  2  inches  above  the  anterior  end  of  the  first 
rib.  Its  highest  point  lies  \  an  inch  above  the  sternal 
end  of  the  clavicle,  in  the  interval  between  the  sternal 
and  clavicular  heads  of  the  sterno-mastoid  muscle.  The 
anterior  edges  of  the  two  lungs  lie  behind  the  sterno- 
clavicular articulations,  pass  obliquely  behind  the  manu- 
brium, and  meet  in  the  middle  line  at  the  junction  of  the 
manubrium  with  the  gladiolus.  The  edge  of  the  right 
lung  then  continues  vertically  downwards  behind  the 
middle  line  of  the  sternum  to  the  sixth  chondro-sternal 
articulation,  where  it  slopes  off  along  the  line  of  the 
sixth  rib.  The  edge  of  the  left  lung  keeps  close  to  that 
of  the  right  as  far  as  the  fourth  chondro-sternal 
articulation,  where  it  turns  off  to  the  left,  following  a  line 
drawn  from  the  fourth  cartilage  to  the  apex  of  the  heart. 
Occasionally  it  does  not  diverge,  but  completely  covers 
the  pericardium  up  to  the  edge  of  the  sternum.  In  the 
child,  owing  to  the  thymus,  the  lungs  are  more  separated 
in  front.     The  right  reaches  the  middle  line,   but  the 


char,.  x.]  The  Thorax.  179 

left  only  reaches  the  left  edge  of  the  sternum  (Syming- 
ton). The  lower  border  of  the  lung  corresponds  to  a 
slightly  convex  line  drawn  round  the  chest  from  the 
sixth  chondro-sternal  articulation  in  front  to  the  eleventh 
dorsal  spine  behind.  In  the  mammary  line  this 
would  correspond  to  the  sixth  rib,  in  the  mid-axillary 
line  to  the  ninth  rib,  and  vertically  downwards 
from  the  inferior  angle  of  the  scapula,  with  the 
tenth  rib.  The  cartilages  of  the  false  and  floating 
ribs  lie  below  the  pleural  line.  The  pleura  extends 
farther  down  than  the  lung,  reaching  in  front  to  the 
level  of  the  seventh  chondro-sternal  union,  behind  to  the 
twelfth  dorsal  spine,  and  at  the  sides  to  a  point  some 
%\  inches  above  the  lower  margin  of  the  thorax.  Thus 
it  will  be  seen  that  the  pleura  and  diaphragm  may 
be  wounded  in  many  places  without  the  lungs  being 
involved.  The  lowest  part  of  the  pleura  is  only  sepa- 
rated from  the  kidneys  by  the  thin  layer  of  the  dia- 
phragm. The  pleura  is  in  relation  with  the  twelfth 
rib,  but  occasionally  it  descends  \  an  inch  or  more  below 
this  point,  and  may  be  wounded  in  operations  on  the 
kidney.  It  extends  lower  clown  in  the  child  than  in 
the  adult.  The  left  lung  descends  to  a  slightly  lower 
level   than   the  right. 

In  penetrating  wounds  involving  the  pleura,  air 
may  enter  the  pleural  cavity,  producing  pneumo-thorax, 
and  this  air  may  be  subsequently  pressed  by  the  respira- 
tory movements  into  the  subcutaneous  tissues  through 
the  wound  in  the  parietal  pleura,  and  lead  to  surgical 
emphysema.  The  cohesion  between  the  smooth  pul- 
monary and  parietal  layers  of  pleura  is  such  that  occa- 
sionally collapse  does  not  follow,  but  the  intimate  connec- 
tion between  them  makes  it  difficult  for  the  pulmonary 
to  escape  when  the  parietal  layer  is  wounded.  In 
wounds  of  the  lung  without  external  wound,  as  when  that 
organ  is  torn  by  a  fractured  rib,  the  air  escapes  from  the 
lung  into  the  pleura,  and  may  thence  pass  into  the  sub- 
cutaneous tissues  through  the  pleural  wound,  thus 
producing  both  pneumo-thorax  and  emphysema. 

It  is  well  to  note  that  emphysema  may  occur  about 


180  Surgical  Applied  Anatomy.       [Chap.  x. 

certain  non-penetrating  wounds  of  the  thorax  when 
'  they  are  of  a  valvular  nature.  In  such  cases  the  air  is 
drawn  into  the  subcutaneous  tissues  during  one  respira- 
tory movement,  and  is  forced  by  another  into  the  cellular 
tissue,  the  valvular  nature  of  the  wound  preventing  its 
escape  externally.  When  the  pleural  "  cavity  "  is  opened, 
the  lungs,  owing  to  the  amount  of  elastic  tissue  they 
contain,  become  more  or  less  collapsed  ;  yet  a  few  cases 
have  been  recorded  where  the  lung  has  protruded  at 
the  time  of  the  accident  through  the  wound  in  the 
parietes.  In  such  instances  the  glottis  must  have 
been  closed,  and  the  lung  fully  distended  at  the 
time  of  the  injury ;  and  it  must  be  further 
assumed  that  the  viscus  was  practically  protruded 
before  air  could  enter  the  pleural  space.  It  is 
noticeable  that  these  recent  hernia?  are  most  common 
at  the  anterior  part  of  the  chest  where  the  lungs  are 
the  most  movable,  and  the  injuries  that  bring  them 
about  are  often  associated  with  violent  respiratory 
efforts  at  the  time  of  the  accident.  In  wounds  of  the 
lung  the  blood  may  escape  in  three  directions  :  into 
the  tissue  of  the  organ  (pulmonary  apoplexy),  into  the 
bronchi  (causing  haemoptysis),  and  into  the  pleura 
(causing  hemothorax).  In  some  instances  the  lung 
has  been  ruptured  without  wound  and  without  frac- 
ture to  the  ribs.  These  cases  are  difficult  to  interpret, 
and  probably  the  best  explanation  suggested  is  that 
put  forward  by  M.  Gosselin.  This  surgeon  believes 
that  at  the  time  of  the  injury  the  lungs  are  suddenly 
filled  and  distended  with  air  by  a  full  inspiration,  and 
that  the  air,  prevented  from  escaping  by  occlusion  of  the 
larynx,  thus  becomes  pent  up  in  the  pulmonary  tissue, 
and  the  lung  not  being  able  to  recede  from  the  super- 
incumbent pressure,  its  structure  necessarily  gives  way. 
Owing  to  the  fineness  of  its  capillaries,  and  to  the 
fact  that  all  venous  blood  returned  to  the  heart  must 
pass  through  the  lungs  before  it  can  reach  other  parts 
of  the  body,  it  follows  that  pysemic  and  other  secondary 
deposits  are  more  commonly  met  with  in  the  lung  than 
in  any  other  of  the  viscera. 


Chap.  X.] 


The  Thorax. 


isi 


Lung  cavities  resulting  from  tuberculosis,  gan- 
grene, or  bronchiectasis,  have  been  successfully  incised 
and  drained,  and  the  same  measure  has  been  applied 
to  hydra  ted  cysts  of  the  lung.     Deep  incisions  in  the  lung 


mkki 


Fig.  ,23.— Diagram  to  show  the  relations  of  the  Heart  to  the  Surface. 
{After  Riidinger.) 

a,  Left  innominate  vein:  b,  right  innominate  vein  ;  c,  superior  vena  cava;  d, 
right  auricle  ;  e,  inferior  vena  cava  ;  /,  aorta  ;  g,  pulmonary  artery;  h,  right 
ventricle  ;  ?',  left  ventricle  ;  j,  left  auricle. 

are  followed  by  less  haemorrhage  than  might  be  expected 
from  such  a  vascular  organ. 

The  trauliea  divides  opposite  the  junction  of  the 
manubrium  and  gladiolus  in  front,  and  the  fourth 
dorsal  vertebra  behind  (Fig.  47,  p.  353).  In  the  newly 
bom  the  trachea  bifurcates  opposite  the  third  vertebra 
(Symington). 


182  Surgical  Applied  Anatomy.       [Chap.  x. 

Certain  foreign  substances  that  have  been  drawn 
into  the  air  passages  have  shown  a  remarkable  facility 
for  escaping  through  the  parietes.  Thus  Mr.  Godlee 
records  the  case  of  a  child  from  an  abscess  in  whose 
back  a  head  of  rye-grass  escaped  that  had  found  its 
way  into  the  air  passages  forty-three  days  previously. 

The  heart. — The  relations  of  the  heart  to  the 
surface  are  as  follows.  Its  upper  limit  corresponds 
to  a  horizontal  line  crossing  the  sternum  about  the 
upper  border  of  the  third  cartilages.  Its  right  border 
to  a  curved  line  arching  from  the  third  right  cartilage 
at  the  sternum  to  the  seventh  right  chondro-sternal 
articulation,  and  reaching  about  1^  inches  from  the 
middle  line.  Its  lower  border  follows  a  line  from  the 
seventh  right  chondro-sternal  articulation  to  the  apex. 
Its  apex  is  opposite  the  fifth  interspace,  at  the  junction 
of  the  ribs,  with  their  cartilages.  Its  base  is  opposite 
the  fifth,  sixth,  seventh  and  eighth  dorsal  vertebra?. 
Its  left  border  is  represented  by  an  arched  line  drawn 
from  the  apex  to  the  third  left  cartilage  at  the  sternum. 

The  orifice  of  the  pulmonary  artery  is  behind  the 
upper  edge  of  the  third  left  cartilage  close  to  the  sternum. 
The  vessel  proceeds  upward  under  cover  of  the  second 
left  outer  space  and  cartilage.  The  aortic  orifice  is  behind 
the  left  border  of  the  sternum  close  to  the  lower 
edge  of  the  third  cartilage.  The  trunk  ascends 
behind  the  second  cartilage  of  the  right  side,  and 
would  be  wounded  by  a  stab  through  that 
cartilage  close  to  the  sternum.  The  concavity  of  the 
aortic  arch  corresponds  to  the  point  between  the 
first  and  second  pieces  of  the  sternum.  The  auriculo- 
ventricular  orifices  are  behind  the  sternum,  the  right 
being  opposite  the  fourth  spaces,  and  the  left  on  a  level 
with  the  fourth  cartilages.  The  innominate  and  left 
carotid  arteries  come  off  at  a  spot  corresponding  to  the 
middle  of  the  manubrium,  and  run  behind  the  right  and 
left  sterno-clavicular  joints  respectively.  The  superior 
vena  cava  would  be  wounded  by  a  knife  entering  either 
the  first  or  the  second  right  interspace  close  to  the 
sternum.     The   left   innominate   vein   lies   transversely 


Chap.  The    Thorax.  iS 


j 


just  below  the  upper  border  of  that  bone.     The  right 

auricle  would  be  wounded  in  stabs  passing  through  the 
sternal  ends  of  the  third,  fourth,  and  fifth  cartilages 
on  the  right  side,  or  through  the  corresponding  inter- 
costal spaces  if  the  knife  were  kept  fairly  near  to  the 
sternum.  (See  Fig.  23,  which  shows  the  relations  of  the 
heart  and  great  vessels  as  given  by  Rudinger.  and  which 
differs  somewhat  from  the  above  account.) 

Wounds  of  the  heart  most  frequently  involve  the 
right  ventricle,   that  segment  of  the  heart  being  the 
part   most   exposed   anteriorly.     Next   in   frequency   is 
the  left  ventricle  wounded,  and  then  the  right  auricle. 
Other  things  being  equal,  a  wound  of  the  ventricle  is 
less  rapidly  fatal  than  is  a  wound  of  the  auricle,  owing 
to  the  thickness  of  the  ventricular  wall,  and  to  its  capacity 
for   contracting   and   preventing  the   escape   of   blood. 
Death  in  cases  of  wound  of  the  heart  would  appear  in 
a  great  number  of  cases  to  be  due  to  an  impression  upon 
the  nervous  centres  rather  than  to  actual  haemorrhage. 
Many  instances  have  been  recorded  to  show  that   the 
heart  may  be  very  tolerant  of  foreign  bodies  in  its  sub- 
stance.    Thus  a  man  lived  for  twenty  days  with  a  skewer 
traversing   the   heart  from  side   to   side  (Ferrus).     In 
another  case  a  lunatic  pushed  an  iron  rod,  over  6  inches 
in  length,  into  his  chest,  until  it  disappeared  from  view, 
although  it  could   be  felt  beneath  the  skin  receiving 
pulsation  from  the  heart.     He  died  a  year  following^ 
and  the   metal  was   found   to   have   pierced  not  only 
the    lungs   but   also   the  ventricular  cavities  (Tillaux). 
Wounds  of  the  heart  have  been  sutured,  the  insertion 
of  the   stitches   causing  only   momentary  disturbance 
of  its  action.     A  propos  of  chest  wounds.  Yelpeau  cites 
the  case  of  a  man  in  whose  thorax  was  found  a  part 
of  a  foil  that  entirely  transfixed  the  chest  from  ribs 
to  spine,  and  that  had  been  introduced  fifteen  years 
before  death.     In  the   museum   of  the   Royal  College 
of  Surgeons  is  the  shaft  of  a  cart  that  had  been  forced 
through  the  ribs  on  the  left  side,  had  passed  entirely 
through  the  chest,  and  had  come  out  through  the  ribs 
on  the  right  side.     The  patient  had  lived  ten  years. 


184  Surgical  Applied  Anatomy.       [Chap.  x. 

Paracentesis  of  the  pericardium  has  been 
performed  through  the  fourth  or  fifth  spaces  on  the 
left  side  close  to  the  sternum,  care  being  taken  to  avoid 
the  internal  mammary  artery.  The  operation  has 
also  been  performed  through  a  trephine  hole  made  in 
the  middle  line  of  the  sternum.  The  extent  to  which 
the  pericardium  is  left  uncovered  by  the  left  pleura 
varies  in  extent,  bat  as  a  rule  it  may  be  tapped  at  any 
point  in  the  fourth  and  fifth  intercostal  spaces,  not 
further  than  an  inch  from  the  sternum,  without  clanger 
to  the  pleura. 

The  niediastina.  —  Abscess  in  the  anterior 
mediastinum  may  have  developed  in  situ,  or  may  have 
spread  down  from  the  neck.  In  like  manner  posterior 
mediastinal  abscesses  may  arise  from  diseases  of  the 
adjacent  spine,  or  lymphatic  glands,  or  may  be  due 
to  the  spreading  downwards  of  a  retro-pharyngeal  or 
retro-cesophageal  collection  of  matter. 

The  azygos  veins,  commencing  as  they  do  below 
in  the  lumbar  veins,  and  having  more  or  less  direct 
communications  with  the  common  iliac,  renal,  and 
other  tributaries  to  the  vena  cava,  are  able  to  a  great 
extent  to  carry  on  the  venous  circulation  in  cases  of 
obstruction  of  the  main  trunk. 

These  veins  are  apt  to  be  pressed  upon  by  tumours 
(such  as  enlarged  gland  masses)  developed  in  the 
posterior  mediastinum,  and  to  produce  in  consequence 
some  oedema  of  the  chest  walls  by  engorgement  of 
those  intercostal  veins  that  they  receive.  Tumours 
growing  in  the  posterior  mediastinum  may  cause  trouble 
by  pressing  upon  the  trachea  or  gullet,  or  by  disturbing 
the  vagus  nerve  or  the  cord  of  the  sympathetic  (Figs. 
47  and  49,  pp.353  and  361).  The  numerous  lymphatic 
glands  which  surround  the  trachea,  bronchi,  and  ceso 
phagus  are  often  the  seat  of  tuberculosis.  They  become 
adherent  to  these  organs  and  may  ulcerate  into  them. 

Krabbel  reports  a  case  of  fracture  of  the  ninth  dorsal 
vertebra  associated  with  rupture  of  the  thoracic  duct. 
The  patient  died  in  a  few  days,  and  the  right  pleura 
was  found  to  contain  more  than  a  gallon  of  pure  chyle. 


}3art  Hi. 

The  Upper  Extremity. 
CHAPTER  XL 

THE   REGION    OF    THE   SHOULDER. 

A  study  of  the  region  of  the  shoulder  comprises 
the  clavicle,  the  scapula,  the  upper  end  of  the  humerus, 
and  the  soft  parts  that  surround  them,  together  with 
the  shoulder  joint  and  axilla. 

Surface  anatomy. — The  clavicle,  acromion 
process,  and  scapular  spine  are  all  subcutaneous,  and 
can  be  readily  felt.  In  the  upright  position,  when  the 
arm  Jiangs  by  the  side,  the  clavicle  is,  as  a  rule,  not 
quite  horizontal.  In  well-developed  subjects  it  inclines 
a  little  upwards  at  its  outer  end.*  In  the  recumbent 
posture,  the  weight  of  the  limb  being  taken  off,  the 
outer  end  rises  still  higher  above  the  sternal  extremity. 
The  degree  of  the  elevation  can  be  best  estimated  by 
a  study  of  frozen  sections.  Thus,  in  making  horizontal 
sections  of  the  body,  layer  by  layer,  from  above  down 
wards,  Braune  found  that  by  the  time  the  sterno- 
clavicular articulation  was  reached,  the  head  of  the 
humerus  would  be  cut  across  in  the  lateral  part  of  the 
section  (Fig.  24). 

The  deltoid  tubercle  of  the  clavicle  may,  if  large, 
be  felt  through  the  skin,  and  be  mistaken  for  an  exostosis. 
The  acromio-clavicular  joint  lies  in  the  plane  of  a  vertical 
line  passing  up  the  middle  of  the  front  of  the  arm.     A 

*  In  some  women,  in  the  feeble,  and  in  some  narrow-shouldered 
men,  the  clavicle  may  be  horizontal,  or  its  outer  end  may  incline 
downwards. 


1S6  Surgical  Applied  Anatomy.      [Chap.  xi. 

prominence  is  sometimes  felt  about  this  joint  in  place 
of  the  level  surface  that  it  should  present.  This  is 
due  to  an  enlargement  of  the  end  of  the  clavicle,  or 
to  a  thickening  of  the  fibro-cartilage  sometimes  found 
in  ths  joint.  In  many  cases  it  has  appeared  to  me 
to  be  due  to  a  trifling  luxation  upwards  of  the  clavicle 
depending  upon  some  stretching  of  the  ligaments. 
It  is  certain  that  the  dry  bone  seldom  shows  such  an 
enlargement  as  to  account  for  this  very  common  prom- 
inence at  the  acromial  articulation.  The  sternal  end 
of  the  clavicle  is  also,  in  muscular  subjects,  often  large 
and  unduly  prominent,  and  sufficiently  conspicuous  to 
suggest  a  lesion  of  the  bone  or  joint  when  none  exists. 

The  roundness  and  prominence  of  the  point  of  the 
shoulder  depend  upon  the  development  of  the  deltoid 
and  the  position  of  the  upper  end  of  the  humerus.  The 
deltoid  hangs  like  a  curtain  from  the  shoulder  girdle, 
and  is  bulged  out,  as  it  were,  by  the  bone  that  it  covers. 
If  the  head  of  the  humerus,  therefore,  be  diminished 
in  bulk,  as  in  some  impacted  fractures  about  the 
anatomical  neck,  or  be  removed  from  the  glenoid  cavity, 
as  in  dislocations,  the  deltoid  becomes  more  or  less 
flattened,  and  the  acromion  proportionately  prominent. 
The  part  of  the  humerus  felt  beneath  the  deltoid  is  not 
the  head,  but  the  tuberosities,  the  greater  tuberosity 
externally,  the  lesser  in  front.  A  considerable  portion 
of  the  head  of  the  bone  can  be  felt  by  the  fingers  placed 
high  up  in  the  axilla,  the  arm  being  forcibly  abducted 
so  as  to  bring  the  head  in  contact  with  the  lower  part 
of  the  capsule.  The  head  of  the  humerus  faces  very 
much  in  the  direction  of  the  internal  condyle.  As 
this  relation,  of  course,  holds  good  in  every  position 
of  the  bone,  it  is  of  value  in  examining  injuries  about 
the  shoulder,  and  in  reducing  dislocations  by  manipula- 
tion, the  condyle  being  used  as  an  index  to  the  position 
of  the  upper  end  of  the  bone. 

In  thin  subjects  the  outline  and  borders  of  the 
scapula  can  be  more  or  less  distinctly  made  out,  but 
in  fat  and  muscular  subjects  all  parts  of  the  bone,  except 
the  spine  and  acromion,  are  difficult  of  access  in  the 


Chap,  xi.]    The  Region  of  the  Shoulder.  1S7 

ordinary  positions  of  the  limb.  To  bring  out  the 
superior  angle  and  vertebral  border  of  the  bone,  the 
hand  of  the  subject  should  be  carried  as  far  as  possible 
over  the  opposite  shoulder.  To  bring  out  the  inferior 
angle  and  axillary  border,  the  fore-arm  should  be  placed 
behind  the  back.  The  angle  formed  at  the  point  of 
junction  of  the  spine  of  the  scapula  and  the  acromion 
is  the  best  point  from  which  to  take  measurement  of 
the  arm,  the  tape  being  carried  down  to  the  external 
condyle  of  the  humerus.  The  upper  border  of  the 
scapula  lies  on  the  second  rib,  its  lower  angle  on  the 
seventh. 

When  the  arm  hangs  from  the  side  with  the  palm 
of  the  hand  directed  forwards,  the  acromion,  external 
condyle,  and  styloid  process  of  the  radius  all  lie  in  the 
same  line.  The  groove  between  the  pectoralis  major 
and  deltoid  muscles  is  usually  to  be  made  out.  In  it 
run  the  cephalic  vein  and  a  large  branch  of  the  acromio- 
thoracic  artery.  Near  the  groove,  and  a  little  below 
the  clavicle,  the  coracoid  process  may  be  felt.  The 
process,  however,  does  not  actually  present  in  the  interval 
between  the  two  muscles,  but  is  covered  by  the  innermost 
fibres  of  the  deltoid.  The  position  of  the  coraco-acromial 
ligament  may  be  defined,  and  a  knife  thrust  through 
the  middle  of  it  should  strike  the  biceps  tendon  and 
open  the  shoulder  joint. 

When  the  arm  hangs  at  the  side  with  the  palm  for- 
wards, the  bicipital  groove  may  possibly  be  defined. 
It  looks  directly  forwards. 

Just  below  the  clavicle  is  a  depression,  the  sub- 
clavicular fossa,  which  varies  considerably  in  depth 
in  different  subjects.  It  is  obliterated  in  subcoracoid 
dislocations  of  the  humerus,  in  fractures  of  the  clavicle 
with  displacement,  by  many  axillary  growths,  and  by 
some  inflammations  of  the  upper  part  of  the  thoracic 
wall.  In  subclavicular  or  intracoracoid  dislocation, 
the  fossa  is  replaced  by  an  eminence.  In  this  region, 
at  a  spot  to  the  inner  side  of  the  coracoid  process,  and 
corresponding  nearly  to  the  middle  of  the  clavicle,  the 
pulsations  of  the  axillary  artery   can  be  felt  on  dec}) 


i88  Surgical  Applied  Anatomy.     [Chap.  xi. 

pressure,  and  the  vessel  be  compressed  against  the 
second  rib.  Just  below  the  clavicle  the  interspace 
between  the  sternal  and  clavicular  portions  of  the 
pectoralis  major  can  often  be  made  out. 

The  anterior  and  posterior  borders  of  the  axilla 
are  very  distinct.  The  anterior  border  formed  by  the 
lower  edge  of  the  pectoralis  major  follows  the  line  of 
the  fifth  rib.  The  depression  of  the  armpit  varies, 
other  things  being  equal,  with  the  position  of  the  upper 
limb.  It  is  most  deep  when  the  arm  is  raised  from 
the  side  at  an  angle  of  about  45°,  and  when  the  muscles 
forming  the  borders  of  the  space  are  in  a  state  of  con- 
traction. As  the  arm  is  raised  above  the  horizontal 
line  the  depression  becomes  shallower,  the  head  of  the 
bono,  projects  into  the  space  and  more  or  less  obliterates 
it,  while  the  width  of  the  fossa  is  encroached  upon  by 
the  approximation  of  the  anterior  and  posterior  folds. 
The  coraco-brachialis  muscle  itself  forms  a  distinct 
projection  along  the  humeral  side  of  the  axilla  when  the 
arm  is  raised  to  a  right  angle  with  the  body.  If  the 
arm  be  brought  nearly  close  to  the  side,  the  surgeon's 
hand  can  be  thrust  well  up  into  the  axilla,  and  the 
thoracic  wall  explored  as  high  up  as  the  third  rib. 

The  axillary  glands  cannot  be  felt  when  they  are 
in  a  normal  condition.  The  central  set  lies  beneath  the 
axillary  tuft  of  hair. 

The  direction  of  the  axillary  artery,  when  the  arm 
is  raised  from  the  side,  is  represented  by  a  line  drawn 
from  about  the  middle  of  the  clavicle  to  the  humerus 
at  the  inner  side  of  the  coraco-brachialis.  A  line  drawn 
from  the  third  rib  near  its  cartilage  to  the  tip  of  the 
coracoid  process  indicates  the  upper  border  of  the 
pectoralis  minor,  and  the  spot  where  this  line  crosses 
the  line  of  the  axillary  artery  points  out  the  position 
of  the  acromio-thoracic  artery.  A  line  drawn  from 
the  fifth  rib  near  its  cartilage  to  the  tip  of  the  coracoid 
process  indicates  the  lower  border  of  the  pectoralis 
minor,  and  the  position  of  the  long  thoracic  artery 
which  runs  along  that  border.  The  line  of  the  sub- 
scapular artery  corresponds  to  the  lower  border  of  the 


chap  xi.]    The  Region  oe  the  Shoulder 


189 


subscapulars  muscle  along  which  it  runs,  but  the  posi- 
tion of  this  border  can  only  be  approximately  indicated 
on  the  living  or  un  dissected  subject. 

The     circumflex     nerve     and    posterior    circumflex 
artery  cross  the  humerus  in  a  horizontal   line    that    is 


2    1  v 


2     J-   V  n  m 


'    /  /  '  !        \ 

l  s 

Fig.  24. — Horizontal  Section  of  the  Body  just  below  the  Upper  Border 
of  the  Manubrium  (Braune). 

it.  Manubrium  ;  b,  head  uf  humerus  ;  c,  clavicle  ;  d,  first  rib  ;  e,  second  rib  ;  /,  third 
dorsd  vertebra  ;  g,  spine  of  second  dorsal ;  h,  pect oralis  major;  i,  deltoid  ; 
/.infraspinatus;  k,  subscapulars ;  I,  coraeo-brachialis  and  biceps:  m,  pec- 
toralis  minor;  n,  serratus  magnus;  0,  intercostals ;  p,  semispinalis  and 
umltifldus  spina;  ;  q,  biventer  cervicis  and  complexus;  r,  longissimus  dorsi  ; 
?,  splen;us  colli  :  t,  rnomboideus ;  u,  trapezius  ;  v.  sterno-tbyroid  ;  w,  sterno- 
hyoid ;  t,  thymus  ;  l,  lung ;  1,  left  innominate  vein  ;  2,  left  carotid  arterj  ; 
,-i,  left  subclavian  artery  :  4,  vertebral  artery  ;  5,  left  subclavian  vein  ; 
G,  cephalic  vein  ;  ',  phrenic  nerve  ;  8,  vagus  ;  9,  transverse  scapular  artery. 


about  a  finger's  breadth  above  the  centre  of  the  vertical 
axis  of  the  deltoid  muscle.  This  point  is  of  importance 
in  cases  of  supposed  contusion  of  the  nerve.  The 
dorsalis  scapula?  artery  crosses  the  axillary  border  of 
the  scapula  at  a  point  corresponding  to  the  centie  of 
the  vertical  axis  of  the  deltoid  muscle.  These  various 
indications  uf    the  positions  of    the  main  branches  of 


igo  Surgical  Aptlied  Anatomy.     [Chap,  xi. 

the  axillary  artery  are  made  while  the  arm  hangs  in 
its  natural  position  at  the  side. 

The  clavicle.— The  skin  over  the  clavicle  is 
loosely  attached,  and  is  easily  displaced  about  the  bone. 
This  circumstance  may  serve  to  explain  why  the  skin 
so  often  escapes  actual  wound  in  contusions  of  the 
clavicular  region,  and  in  part  explains  the  infrequency 
of  penetration  of  the  integument  in  fractures  of  the 
clavicle.  The  position  of  the  supra-clavicular  nerves 
in  front  of  the  bone  renders  them  very  liable  to  con- 
tusion, and  accounts  for  the  unusual  amount  of  pain 
that  is  said  to  sometimes  follow  blows  over  the  collar 
bone.  Tillaux  believes  that  the  severe  pain  that  in 
rare  cases  persists  after  fracture  of  the  clavicle  is 
due  to  the  implication  of  these  nerves  in  the  callus  formed. 
The  three  nerves  that  cross  the  clavicle  are  branches 
of  the  third  and  fourth  cervical  nerves,  and  it  is  well  to 
note  that  pain  over  the  collar  bone  is  sometimes  a  marked 
feature  in  disease  of  the  upper  cervical  spine.  This 
symptom  is  then  due  to  irritation  of  these  nerves  at 
their  points  of  exit  from  the  spinal  canal. 

Beneath  the  clavicle  the  great  vessels  and  the  great 
nerve-cords  lie  upon  the  first  rib.  The  vein  is  the  most 
internal,  and  occupies  the  acute  angle  between  the 
collar  bone  and  the  first  rib.  It  will  be  seen  that  growths 
from  the  bone  may  readily  press  upon  these  important 
structures,  and  that  the  vein,  from  its  position,  as  well 
as  from  the  slighter  resistance  that  it  offers,  is  likely 
to  be  the  first  to  be  compressed.  These  structures  have 
also  been  wounded  by  fragments  of  bone  in  fracture 
of  the  clavicle.  Fortunately,  between  the  clavicle  and 
these  large  nerves  and  vessels  the  subclavius  muscle  is 
interposed.  This  muscle  is  closely  attached  to  the  under 
surface  of  the  bone,  is  enveloped  in  a  dense  fascia,  and 
forms  one  of  the  chief  protections  to  the  vessels  in  case 
of  fracture.  This  interposing  pad  of  muscle  is  also  of 
great  service  in  resection  operations,  as  can  be  well 
understood.  Braune  states  that  by  pressing  the  clavicle 
against  the  first  rib  in  the  dead  body  a  stream  of  injection 
in  the  thoracic  duct  can,  in  some   cases,    be    entirely 


chap.  xi. i    The  Region  of  the  Shoulder.  191 

arrested.  Behind  the  clavicle  the  following  structures 
may  be  noted,  viz.,  the  innominate,  subclavian,  and 
external  jugular  veins,  the  subclavian,  suprascapular, 
and  internal  mammary  arteries,  the  cords  of  the  brachial 
plexus,  the  phrenic  nerve  and  nerve  of  Bell,  the  thoracic 
duct,  the  omo-hyoid,  scalene  sternohyoid  and  sterno- 
thyroid muscles,  the  apex  of  the  lung.  The  sternal 
end  of  the  bone  is  not  far  removed  from  the  innominate 
or  left  carotid  artery,  the  vagus  and  recurrent  nerves, 
the  trachea,  and  the  oesophagus. 

These  relations  of  the  clavicle  are  given  to  show  the 
dangers  in  the  way  of  partial  or  complete  resections  of 
the  bone.  The  difficulties  and  risks  of  the  operation 
increase  as  one  progresses  from  the  acromial  to  the 
sternal  end.  Resection  of  the  acromial  third  of  the 
bone  is  comparatively  easy,  but  resection  of  the  sternal 
portion  is  most  difficult  and  dangerous.  The  entire 
clavicle  has  been  removed  with  success,  and  the  operation 
has  been  followed  by  less  impairment  of  the  arm  move- 
ments than  would  be  imagined. 

The  clavicle  forms  the  sole  direct  bony  connection 
between  the  upper  limb  and  the  trunk,  and  in  severe 
accidents,  this  connection  being  broken  through,  it  is 
possible  for  the  extremity  to  be  torn  off  entire.  Thus 
Billroth  reports  the  case  of  a  boy  aged  fourteen,  whose 
right  arm,  with  the  scapula  and  clavicle,  was  so  torn 
from  the  trunk  by  a  machine  accident  that  it  was  only 
attached  by  a  strip  of  skin  two  inches  wide.  Other 
like  cases  of  avulsion  of  the  limb  have  been  reported. 

Fractures  of  clavicle. — The  clavicle  is  more 
frequently  broken  than  is  any  other  single  bone  in 
the  body.  This  frequency  is  explained  by  the  lad 
that  the  bone  is  very  superficial,  is  in  a  part  exposed 
to  injury,  is  slender  and  contains  much  compact  tissue, 
is  ossified  at  a  very  early  period  of  life,  and  above  all 
receives  a  large  part  of  all  shocks  communicated  to 
the  upper  extremity.  The  common  fracture,  that 
due  to  indirect  violence,  is  oblique,  and  very  constant 
in  its  position,  viz.  at  the  outer  end  of  the  middle  third 
of  the   bone.     The   bone   breaks   at    this   spot   for   the 


ig2  Surgical  Applied  Anatomy.     [Chap.'xi. 

following  reasons.  It  is  here  that  the  clavicle  is  the 
most  slender  ;  it  is  here  that  the  two  curves  of  the 
bone  meet ;  it  is  here  that  a  very  fixed  part  of  the  bone, 
viz.  the  outer  third,  joins  with  a  more  movable  portion. 
The  position  of  the  coraco-clavicular  ligaments  is  no 
doubt  of  the  greatest  import  in  localising  the  fracture 
in  this  position,  since  a  clavicle  experimentally  subjected 
to  longitudinal  compression  does  not  break  at  this  spot 
(Bennett).  The  displacement  that  occurs  is  as  follows. 
The  inner  fragment  remains  unchanged  in  position, 
or  its  outer  end  is  drawn  a  little  upwards  by  the  sterno- 
mastoid.  It  will  be  seen  that  any  action  of  this  muscle 
would  be  resisted  by  the  pectoralis  major  and  the 
rhomboid  ligament.  The  outer  fragment  undergoes  a 
threefold  displacement.  (1)  It  is  carried  directly  down- 
wards. This  is  effected  mainly  by  the  weight  of  the 
limb  aided  by  the  pectoralis  minor,  the  lower  fibres  of 
the  pectoralis  major,  and  the  latissimus  dorsi.  Since 
the  line  of  action  of  the  trapezius  muscle  is  altered  by 
the  fracture,  that  muscle  is  no  longer  able  to  keep  the 
shoulder  up,  and  its  altered  action  therefore  contributes 
to  the  downward  displacement.  (2)  It  is  carried  directly 
inwards  by  the  muscles  that  pass  from  the  trunk  to  the 
shoulder,  viz.  the  trapezius,  the  levator  anguli  scapuhe, 
the  rhomboids,  the  latissimus  dorsi,  and  especially  by 
the  pectorals.  To  these  may  be  added  the  subclavius. 
(3)  The  fragment  is  rotated  in  such  a  way  that  the 
outer  end  projects  forwards,  the  inner  end  backwards. 
This  rotation  is  brought  about  mainly  by  the  two 
pectorals,  assisted  prominently  by  the  serratus  magnus. 
The  normal  action  of  this  latter  muscle  is  to  carry  the 
scapula  forwards,  and  the  clavicle,  acting  as  a  kind 
of  outrigger  to  keep  the  upper  limb  at  a  proper  distance 
from  the  trunk,  moves  forwards  at  the  same  time  and 
keeps  the  scapula  direct.  When  this  outrigger  is  broken 
the  serratus  can  no  longer  carry  the  scapula  directly 
forwards.  The  bone  tends  to  turn  towards  the  trunk, 
and  the  point  of  the  shoulder  is  therefore  seen  to  move 
inwards  as  well  as  forwards.  The  fragments  in  this 
fracture   must   consequently   overlap,   and   as  the  dis- 


Chap,  xi.]    The  Region  of   the  Shoulder.  193 

placement  is  difficult  to  remedy,  it  follows  that  in  no 
bone  save  the  femur  is  shortening  so  uniformly  left 
as  after  an  oblique  fracture  of  the  clavicle.  The  degree 
of  shortening  very  seldom  exceeds  one  inch.  The 
deformity  associated  with  this  fracture  is  well  remedied 
when  the  patient  assumes  the  recumbent  position. 
In  this  posture,  the  weight  of  the  limb  being  taken 
off,  the  downward  displacement  is  at  once  remedied. 
The  point  of  the  shoulder  falling  back  also  tends  to  relieve 
in  part  the  inward  displacement,  and  the  rotation  of 
the  outer  fragment  forwards.  It  is  through  the  scapula, 
however,  that  these  two  latter  displacements  are  in 
the  main  removed.  In  the  recumbent  posture  the 
scapula  is  pressed  closely  against  the  thorax,  with 
the  result  that  its  outer  extremity  (and  with  it,  of  course, 
the  outer  fragment  of  the  clavicle)  is  dragged  outwards 
and  backwards.  Some  surgeons,  recognising  this  im- 
portant action  of  the  scapula  in  remedying  the  dis- 
placement in  these  cases,  strap  the  scapula  firmly  against 
the  trunk,  while  at  the  same  time  they  elevate  the  arm. 

Fractures  due  to  direct  violence  are  usually 
transverse,  and  may  be  at  any  part  of  the  bone.  When 
about  the  middle  third  they  present  the  displacement 
just  described.  When  the  fracture  is  between  the 
conoid  and  trapezoid  ligaments  no  displacement  is 
possible.  When  beyond  these  ligaments,  the  outer  end  of 
the  outer  fragment  is  carried  forwards  by  the  pectorals 
and  serratus,  and  its  inner  end  is  a  little  drawn  up  by 
the  trapezius.  In  this  fracture  there  is  no  general 
displacement  downwards  of  the  outer  fragment,  since 
it  cannot  move  in  that  direction  unless  the  scapula 
go  with  it,  and  the  scapula  remains  fixed  by  the  coraco- 
clavicular  ligaments  to  the  inner  fragment  of  the  clavicle. 

The  clavicle  may  be  broken  by  muscular  violence 
alone.  Polaillon,  from  a  careful  analysis  of  the 
reported  cases,  concludes  that  the  muscles  that  break 
the  bone  are  the  deltoid  and  clavicular  part  of  the  great 
pectoral.  In  no  case  does  the  fracture  appear  to  have 
been  produced  by  the  sterno-mastoid  muscle.  The 
commonest  movements   producing  fracture   appear  to 

N 


1 94  Surgical  Applied  Anatomy.      [Chap.  xi. 

be  violent  movements  of  the  limb  forwards  and  inwards, 
or  upwards.  These  fractures  are  usually  about  the 
middle  of  the  bone,  and  show  no  displacement  other 
than  that  of  both  fragments  forwards,  i.e.  in  the  direction 
of  the  fibres  of  the  two  muscles  first  named. 

The  clavicle  is  more  frequently  the  seat  of  green-stick 
fracture  than  is  any  other  bone  in  the  body.  Indeed, 
one-half  of  the  cases  of  broken  collar  bone  occur  before 
the  age  of  five  years.  This  is  explained  by  the  fact 
that  the  bone  is  ossified  at  a  very  early  period,  and  is 
in  a  breakable  condition  at  a  time  when  most  of  the 
other  long  bones  still  present  much  unossified  cartilage 
in  their  parts.  Moreover,  the  periosteum  of  the  clavicle 
is  unduly  thick,  and  not  very  closely  attached  to  the 
bone,  circumstances  that  greatly  favour  subperiosteal 
fracture. 

A  reference  to  the  relations  of  the  bone  will  show 
that  important  structures  may  be  wounded  in  severe 
fractures  associated  with  much  displacement  and  with 
sharp  fragments.  Several  cases  are  reported  of  paralysis 
of  the  upper  limb  (as  a  rule  incomplete)  following  upon 
fracture  of  this  bone.  In  some  cases  this  symptom 
was  due  to  actual  compression,  or  tearing  of  some  of 
the  great  nerve  cords  by  the  displaced  fragments.  In 
other  cases  the  nerve  injury,  while  due  to  the  original 
accident,  was  yet  independent  of  the  broken  clavicle. 
Paralysis  of  the  biceps,  brachialis  anticus  and  supinator 
longus,  muscles  supplied  through  the  upper  cord,  may 
result  from  heavy  weights  being  carried  on  the  shoulder. 
Cases  are  reported  of  wound  of  the  subclavian  artery, 
of  the  subclavian  vein,  of  the  internal  jugular  vein, 
and  of  the  acromio-thoracic  artery.  In  several  instances 
the  fracture  has  been  associated  with  wound  of  the 
lung,  with  or  without  a  fracture  of  the  upper  ribs. 

The  clavicle  begins  to  ossify  before  any  bone  in 
the  body.  At  birth  the  entire  shaft  is  bony,  the  two 
ends  being  still  cartilaginous.  The  bone  has  one 
epiphysis  for  its  sternal  end  that  appears  between  the 
eighteenth  and  twentieth  year,  and  joins  the  shaft 
about  twenty-five.    It  is  a  mere  shell,  is  closely  sur- 


Chap,  xi.]    The  Regiox  of  the  Shoulder.  195 

rounded    by  the  ligaments   of   the   sternal  joint,   and 
cannot,  therefore,  be  well  separated  by  accident.* 

Sterno-claviculai-  joint. — Although  this  is 
the  only  articulation  that  directly  connects  the  upper 
limb  with  the  trunk,  yet  it  -is  possessed  of  such  con- 
siderable strength  that  luxation  at  the  joint  is  com-" 
paratively  rare.  The  amount  of  movement  in  the 
joint  depends  to  a  great  extent  upon  the  lack  of  adapta- 
bility between  the  facet  on  the  sternum  and  the  sternal 
end  of  the  clavicle.  The  disproportion  between  these 
parts  is  maintained  by  the  inter-articular  cartilage, 
which  reproduces  only  the  outline  of  the  clavicular 
surface.  The  cavity  of  the  joint  is  V-shaped,  since 
the  clavicle  only  touches  the  socket  at  its  inferior  angle 
when  the  arm  hangs  by  the  side.  When  the  arm  is 
elevated,  however,  the  two  bones  are  brought  in  more 
immediate  contact,  and  the  joint  cavity  becomes  a  mere 
slit.  Thus,  in  disease  of  this  articulation  it  will  be 
found  that  of  all  movements  of  the  joint  the  movement 
of  the  limb  upwards  is  the  most  constant  in  producing 
pain.     The  joint  is  supplied  by  the  suprasternal  nerve. 

The  movements  permitted  at  this  point  are  limited, 
owing  to  the  anterior  and  posterior  ster  no-clavicular 
ligaments  being  moderately  tense  in  all  positions  of  the 
clavicle.  Movement  forwards  of  the  clavicle  on  the 
sternum  is  checked  by  the  posterior  ligament,  and 
resisted  by  the  anterior  ligament.  This  latter  ligament 
is  more  lax  and  less  substantial  than  is  the  posterior 
band.  Its  weakness  serves  in  part  to  explain  the  fre- 
quency of  the  dislocation  forwards. 

Movement  of  the  clavicle  backwards  on  the  sternum^ 
is  checkedjby  the  anterior  ligament,  while  the  passage 
of  the  head  of  the  bone  is  resisted  by  the  powerful  pos- 
terior band.     The   movement  is  also  opposed  by  the 
rhomboid  ligament.    To  produce,  therefore,  a  dislocation 

*  Mr.  Heath  (Lancet,  Nov.  18,  1882)  reports  a  case  which  is 
probably  unique.  It  concerns  a  lad,  aged  14,  who,  when  in  the 
act  of  bowling  at  cricket,  tore  the  clavicle  away  from  its  epiphyseal 
cartilage,  which  remained  m  situ.  The  rmiscle  producing  the 
accident  was  apparently  the  pectoralis  major. 


196  Surgical  Applied  Anatomy.     [Chap.  xi. 

backwards  considerable  force  must  be  used.  Movement 
of  the  clavicle  upwards  on  the  sternum  is  checked  by 
the  rhomboid  ligament,  the  interclavicular  ligament,  the 
interarticular  cartilage,  and  in  a  less  direct  manner  by 
the  two  remaining  ligaments  of  the  joint.  Thus  it 
happens  that  dislocation  upwards  is  the  least  common 
of  the  luxations  at  this  articulation. 

Disease  of  the  sterno-clavicular  joint.— 
This  articulation  is  really  divided  into  two  joints  by 
the  interarticular  cartilage,  each  being  provided  with 
a  distinct  synovial  membrane. 

These  joints  are  liable  to  the  ordinary  maladies  of 
joints,  and  it  would  appear  that  the  disease  may 
commence  in,  and  be  for  some  time  limited  to,  one  only 
of  the  synovial  sacs.  In  time  the  whole  articulation 
usually  Decomes  involved,  but  even  in  advanced  cases 
the  mischief  is  sometimes  restricted  to  the  synovial 
cavity  on  one  side  of  the  cartilage.  According  to 
some  authors,  this  joint  is  more  frequently  involved 
in  pyaemia  than  is  any  other.  When  effusion  has  taken 
place  into  the  sterno-clavicular  joint,  and  especially 
after  suppuration  has  ensued,  the  swelling  usually  makes 
itself  evident  in  front,  owing  to  the  fact  that  the  anterior 
sterno-clavicular  ligament  is  the  thinnest  and  least 
resisting  of  the  ligamentous  structures  about  the  articu- 
lation. For  the  same  reason  the  pus  usually  escapes 
from  the  anterior  surface,  when  it  discharges  itself 
spontaneously.  It  may,  however,  make  an  opening 
for  escape  through  the  posterior  ligament,  and  under 
these  circumstances  has  found  its  way  into  the  medias- 
tinum. The  relations  of  this  joint  to  the  great  vessels 
at  the  root  of  the  neck  should  be  borne  in  mind.  In 
one  case  reported  bjr  Hilton  a  large  abscess  formed  in 
the  articulation,  and  the  collection,  receiving  pulsations 
from  the  subjacent  artery  (the  innominate  or  right 
subclavian),  was  supposed  at  one  time  to  be  an  aneurism. 
It  is  remarkable  that  disease  of  this  joint  never  leads 
to  anchylosis.  This  circumstance  may  be  explained 
(1)  by  the  constant  slight  movement  in  the  part,  which 
prevents  the  diseased  structures  from  being  kept  at  rest, 


chap,  xi.]    The  Region  of  the  Shoulder.  197 

(2)  by  the  occasional  persistence  of  the  interarticular 
cartilage,  and  (3)  by  the  utter  lack  of  adaptability  of 
the  two  bony  surfaces  involved. 

Dislocations  of  the  sterno-clavicnlar  joint. 

— The  clavicle  may  be  dislocated  from  the  sternum  in 
one  of  three  directions,  which,  given  in  order  of  fre- 
quency, are  :  (1)  forwards,  (2)  backwards,  (3)  upwards. 
The  relative  frequency  of  these  dislocations  can  be 
understood  from  what  has  been -already  said  as  to  the 
action  of  the  ligaments  in  restricting  movements. 
The  displacement  forwards  involves  entire  rupture  of 
the  capsule,  and  more  or  less  damage  to  the  rhomboid 
ligament.  The  head  of  the  bone,  carrying  with  it  the 
sterno-mastoid,  rests  on  the  front  of  the  manubrium. 
The  dislocation  backwards  may  be  due  to  direct  or 
indirect  violence,  and  has  occurred  spontaneously  in 
connection  with  the  chest  deformity  in  Pott's  disease. 
The  capsule  is  entirely  torn,  as  is  also  the  rhomboid  liga- 
ment. The  head  is  found  in  the  connective  tissue  behind 
the  sterno-hyoid  and  sterno-thyroid  muscles.  In  this 
position  it  may  cause  severe  dyspncea,  or  dysphagia, 
by  pressure  upon  the  trachea  or  gullet.  It  may  so 
compress  the  subclavian  artery  as  to  arrest  the  pulse 
at  the  wrist,  or  so  occlude  the  innominate  vein  as  to 
produce  semi-coma  (Fig.  24,  p.  189).  In  one  case  the  head 
of  the  bone  had  to  be  excised  to  relieve  a  troublesome 
dysphagia.  In  the  luxation  upwards,  due  usually  to 
indirect  violence,  the  head  rests  on  the  upper  border 
of  the  sternum  between  the  sterno-mastoid  and  sterno- 
hyoid muscles.  It  involves  more-  or  less  complete 
tearing  of  all  the  ligaments  of  the  joint,  together  with 
avulsion  of  the  interarticular  fibro-cartilage. 

The  non-adaptability  of  the  joint  surfaces  in  this 
part  serves  to  explain  the  ease  with  which  these 
luxations  are  usually  reduced,  and  the  difficulty 
of  retaining  the  clavicle  in  position  after  it  is  replaced. 
Acromioclavicular  joint. — This  articulation 
is  shallow,  and  the  outlines  of  the  two  bones  that  enter 
into  its  formation  are  such  that  no  obstacle  is  offered 
to  the  displacement  of  the  clavicle  from  the  acromion. 


198  Surgical   Applied  Anatomy.     [Chap. xi. 

The  joint,  indeed,  depends  for  its  strength  almost  entirely 
upon  its  ligaments.  The  plane  of  the  joint  would  be 
represented  by  a  line  drawn  from  above  downwards 
and  inwards  between  the  two  bones.  This  inclination  of 
the  joint  surfaces  serves  to  explain  the  fact  that  the 
usual  luxation  of  this  part  takes  the  form  of  a  displace- 
ment of  the  clavicle  upwards  on  to  the  acromion.  The 
capsule  that  surrounds  the  joint  is  lax  and  feeble,  and 
it  is  partly  from  its  comparative  thinness  that  effusion 
into  this  joint,  when  it  is  the  seat  of  disease,  makes  itself 
so  soon  visible.  The  joint,  however,  depends  mainly 
for  its  strength  upon  the  powerful  conoid  and  trapezoid 
ligaments.  The  effects  of  shock  at  this  joint  are  lessened 
by  the  presence  of  a  partial  fibro-cartilage  which  projects 
between  the  bones  from  the  upper  part  of  the  capsule. 

As  the  movements  permitted  in  this  joint  may  be 
impaired  by  accident  or  disease,  it  is  well  to  note  the 
part  the  articulation  takes  in  the  movements  of  the 
extremity.  The  scapula  (and  with  it,  of  course,  the 
arm),  as  it  glides  forwards  and  backwards  upon  the 
thorax,  moves  in  the  arc  of  a  circle  whose  centre  is  at 
the  ster no-clavicular  joint,  and  whose  radius  is  the 
clavicle.  As  the  bone  moves  forwards  it  is  important, 
for  reasons  to  be  immediately  given,  that  the  glenoid 
cavity  should  also  be  directed  obliquely  forwards.  This 
latter  desirable  condition  is  brought  about  by  means 
of  the  acromio-clavicular  joint.  Without  this  joint 
the  whole  scapula  as  it  passed  forwards  with  the  outer 
end  of  the  clavicle  would  precisely  follow  the  line  of  the 
circle 'above  mentioned,  and  the  glenoid  cavity  would 
look  in  an  increasingly  inward  direction.  It  is  essential 
that  the  surface  of  the  glenoid  cavity  should  be  main- 
tained as  far  as  possible  at  right  angles  to  the  long  axis 
of  the  humerus.  When  these  relations  are  satisfied, 
the  humerus  has  the  support  behind  of  a  stout  surface 
of  bone,  and  it  is  partly  to  obtain  the  value  of  this  support 
that  the  boxer  strikes  out  from  the  side,  i.e.  with  his 
humerus  well  backed  up  by  the  scapula.  If  there  were 
no  acromio-clavicular  joint  the  glenoid  fossa  would 
offer  little  support  to  the  humerus  when  the  limb  was 


Chap,  xi.]    The  Region  of  the  Shoulder.  199 

stretched  forwards,  and  a  blow  given  with  the  limb  in 
that  position,  or  a  fall  upon  the  hand  under  like  con- 
ditions, would  tend  to  throw  the  humerus  against  the 
capsule  of  the  shoulder  joint,  and  so  produce  dislocation. 
Normally,  therefore,  as  the  scapula  and  arm  advance, 
the  angle  between  the  posterior  border  of  the  acromion 
and  the  adjacent  portion  of  the  clavicle  becomes  more 
and  more  acute,  and  the  glenoid  fossa  is  maintained 
with  a  sufficiently  forward  direction  to  give  substantial 
support  to  the  humerus.*  It  will  thus  be  seen  that 
rigidity  of  this  little  joint  may  be  a  cause  of  insecurity 
in  the  articulation  of  the  shoulder,  and  of  weakness 
in  certain  movements  in  the  limb. 

Dislocations  of  the  acromio  -  clavicular 
joint. — The  clavicle  may  be  displaced  upwards  on 
to  the  acromion  or  downwards  beneath  it.  Pollaillon 
has  collected  thirty-eight  cases  of  the  former  luxation, 
and  six  only  of  the  latter.  This  disproportion  is,  in 
the  main,  explained  by  the  direction  of  the  articulating 
surfaces  of  the  joint,  Both  luxations  are  usually  due 
to  direct  violence.  The  dislocation  upwards  is  very 
commonly  only  partial,  and  is  associated  only  with 
stretching  and  some  trifling  rupture  of  ligaments.  In 
the  complete  form,  where  the  end  of  the  clavicle  rests 
entirely  upon  the  acromion,  there  is  rupture,  not  only 
of  the  capsule,  but  also  to  a  greater  or  less  extent  of 
the  coraco-clavicular  ligaments.  In  the  complete  dis- 
location downwards,  also,  there  is  a  rupture  of  the 
capsule,  with  extensive  tearing  of  the  conoid  and  trape- 
zoid ligaments.  These  luxations  are  usually  easily 
reduced,  but  it  will  be  understood,  from  the  direction 
of  the  articular  surfaces,  that  in  the  displacement  upwards 
it  is  very  difficult  to  retain  the  clavicle  in  situ  when 
once  reduced. 

Scapula. — At  the  posterior  aspect  of  the  Lone 
the  muscles  immediately  above  and  below  the  spine 
are  somewhat  precisely  bound  down  by  the  deep  fascia. 
Thus,  the  supraspinatus  muscle  is  enclosed  in  a  fascia, 

*  For  an  excellent  account  of  the  mechanism  of  these  joints 
see  Morris's  "  Anatomy  of  the  Joints,''  p.  202  tt  seq.     1879. 


2  o  o  Sur  gica  l  Applied  Ana  to  my.     [  chap,  x  i . 

-that,  being  attached  to  the  bone  all  round  the  origin 
of  the  muscle,  forms  a  cavity  open  only  towards  the 
insertion  of  the  muscle. 

The  infraspinatus  and  teres  minor  muscles  arc  also 
enclosed  in  a  distinct,  but  much  denser,  fascia  that  is 
attached  to  the  bone  beyond  these  muscles,  and  blends 
in  front  with  the  deltoid  sheath  so  as  to  form  a  second 
enclosed  space.  The  arrangement  of  these  fasciae 
serves  to  explain  the  trifling  amount  of  ecchymosis 
that  usually  follows  upon  fractures  of  the  scapular 
blade.  The  extravasation  of  blood  about  the  fracture 
is  bound  down  by  the  fasciae  over  these  muscles,  and 
is  unable,  therefore,  to  reach  the  surface. 

Thus  also  pus,  in  the  supra-  and  infra-spinous  fossae, 
tends  to  be  pent  up,  and  to  come  forward  in  the  one 
case  at  the  insertion  of  the  subscapular  muscle,  and 
in  the  other  instance  about  the  insertion  of  the  teres 
minor.  Owing  to  the  rigidity  of  the  fascia  over  the 
infraspinatus  and  teres  minor  muscles,  it  happens  that 
dense  tumours  growing  from  this  fascia  may  readily 
be  mistaken  for  growths  from  the  bone  itself. 

The  inferior  angle  of  the  scapula  is  crossed  by  a 
part  of  the  latissimus  dorsi,  and  by  means  of  this  muscle 
is  retained  in  contact  with  the  thorax.  In  certain 
injuries  the  angle  may  slip  from  beneath  the  muscle 
and  appear  as  a  marked  projection.  This  lesion  is 
productive  of  some  loss  of  power  in  the  limb.  In  many 
cases  where  this  accident  is  supposed  to  have  occurred, 
it  is  probable  that  the  symptoms  present  are  due  rather 
to  paralysis  of  the  nerve  of  Bell. 

Fractures  of  the  scapula,  and  especially  of 
the  body  of  the  bone,  are  not  common,  owing  to  the 
mobility  of  the  part  and  the  thick  muscles  that  cover 
in  and  protect  its  thinner  portions.  It  rests  also  upon 
a  soft  muscular  pad,  and  derives,  no  doubt,  additional 
security  from  the  elasticity  of  the  ribs. 

The  most  common  lesion  is  a  fracture  of  the  acromion 
process.  This  is  often  but  a  separation  of  the  epiphysis. 
There  are  two,  sometimes  three,  epiphyseal  centres 
for  the  acromion.     Ossification  appears  in  them  about 


chap,  xi.]    The  Region  oe  the  Shoulder.  201 

puberty,  nnd  the  entire  epiphysis  joins  with  the  rest 
of  the  bone  from  1  ho  twenty-second  to  the  twenty-fifth 

year.     Several  cases  of  supposed  fracture  of  the  acromion 
united    by   fibrous   tissue    are    probably    but   instances 
of  an  imperfectly-united  epiphysis,  and  may  have  been 
independent   of   injury.     In    five    bodies   out    of   forty 
Symington  found  the  acromial  epiphysis  united  to  the 
spine  by  a  fibrous  union,  and  from  the  statistics  of  other 
observers  it  appears  that  this  is  the  case  in  quite  10  per 
cent,  of  adults.     In  fractures  of  the  process  much  dis- 
placement  is    quite    uncommon,    owing   to    the    dense 
fibrous  covering  the  bone  derives  from  the  two  muscles 
attached   to   it.     This   dense   periosteum   also   explains 
the  circumstance  that   many  fractures  are  incomplete 
and   crepitus   often   absent.     When   the  fracture   is  in 
front  of  the  clavicular  joint,  displacement  of  the  arm 
is  impossible.     When  it  involves  the  joint,  a  dislocation 
of  the  collar-bone  is  common.     When  behind  the  joint, 
the  arm,  having  lost  its  support  from  the  thorax,   is 
displaced  in  somewhat  the  same  way  as  obtains  in  the 
common  fracture  of  the  clavicle.     The  coracoid  process 
may  present  a  genuine  fracture,  or  may  be  separated 
as   an  epiphysis.     As   an  epiphysis,   it   joins   the   main 
bone  about  the  age  of  seventeen.     The  supra-glenoid 
tubercle,  from  which  the  long  head  of  the  biceps  takes 
it^  origin,  is  part  of  the  coracoid  epiphysis.     In  spite 
of  the  powerful  muscles  attached  to  it,  the  displacement 
is    usually    slight,    inasmuch    as    the    coraco-clavicular 
ligaments  are  seldom  torn.     These  ligaments,  it  may 
be  noted,  are  attached  to  the  base  of  the  process.     In 
some  few  cases  the  process  has  been  torn  oft"  by  muscular 
violence. 

Among  the  more  usual  fracture-;  of  the  body  of  the 
scapula  is  a  transverse  or  oblique  fracture  of  its  blade 
below  the  spine.  Owing  to  the  infraspinatus,  sub- 
scapulars, and  other  muscles  being  attached  to  both  frag- 
ments, none  but  a  trifling  displacement  is  usual.  A 
fracture  may  occur  through  the  surgical  neck.  The 
surgical  neck  is  represented  by  a  narrowed  part  of  the. 
bone  behind  the  glenoid  fossa,   and  in  the  line  of  the 


2  O  2  Sl/P  GICA  L    A  PPL  I  ED    A  NA  TOM  V.        [Chap.  XI . 

suprascapular  notch.  The  smaller  fragment  will,  there- 
fore, include  the  coracoid  process,  the  larger,  the 
acromion.  The  amount  of  deformity  in  these  cases 
depends  upon  whether  the  coraco-clavicular  and  acromio- 
clavicular ligaments  are  entire  or  torn.  If  they  he 
torn,  the  small  fragments  and  the  entire  limb  are 
displaced  downwards,  and  the  injury  somewhat  resembles 
a  subglenoid  dislocation.  From  this,  however,  it  is 
distinguished  by  the  crepitus,  by  the  ease  with  which 
the  deformity  is  removed  and  the  equal  ease  with  which 
it  returns,  by  the  position  of  the  head  of  the  humerus 
in  regard  to  the  glenoid  fossa,  and  by  the  conspicuous 
fact  that  the  coracoid  process  is  displaced  downwards 
with  the  limb. 

Tumours  of  various  kinds  grow  from  the  scapula 
and  mainly  from  the  spongy  parts  of  the  bone,  viz., 
the  spine,  the  neck,  the  inferior  angle.  The  bone  may 
be  removed  entire,  with  or  without  amputation  of 
the  upper  limb.  An  inter-scapulo-thoracic  amputation 
is  usually  performed  for  malignant  tumours  which 
involve  structures  in  the  neighbourhood  of  the  shoulder 
joint.  In  this  operation  the  upper  extremity,  including 
the  scapula  and  the  clavicle  beyond  the  origin  of  the 
sterno-mastoid,  is  removed.  An  elliptical  incision  is 
made  in  front  and  behind  the  shoulder,  the  upper  end 
of  the  ellipse  lying  on  the  clavicle,  the  lower  at  the  angle 
of  the  scapula.  The  operation  is  commenced  at  the 
clavicle  so  as  to  secure  the  axillary  vessels.  The  artery 
is  tied  before  the  vein  so  that  the  limb  may  continue 
to  empty  its  blood  into  the  circulation.  The  main 
vessels  to  be  noted  in  connection  with  this  operation 
are  the  suprascapular  at  the  superior  border  of  the 
bone,  the  posterior  scapular  about  the  vertebral  border, 
the  subscapular  running  along  the  lower  border  of  the 
subscapularis  muscle,  the  dorsalis  scapulae  crossing  the 
axillary  edge  of  the  bone,  and  the  acromial  branches 
of  the  acromio-thoracic  artery. 

The  axilla. — The  axilla  may  be  regarded  surgically 
as  a  passage  between  the  neck  and  the  upper  limb. 
Axillary  tumours  and   abscesses   may  spread   up  into 


CI 


lap, 


XL]    The  Region  or  the  Shoulder. 


20' 


the  neck,  and  in  like  manner  cervical  growths  and 
purulent  collections  may  extend  to  the  arm-pit.  The 
skin  forming  the  hase  of  the  axilla  is  provided  with 
many  short  hairs  and  with  numerous  sebaceous  and 
sudoriferous  glands.  In  this  integument  small  super- 
ficial abscesses  are  often  met  with,  that  arise  usually 
from  suppuration  of 
these  glandular 
structures,  and  that 
are  brought  about 
by  the  friction  of  the 
skin  against  the 
clothing.  Owing  to 
the  tendency  of  the 
axillary  integument 
to  become  chafed 
and  inflamed  under 
friction,  the  axilla  is 
not  a  good  locality 
to  select  for  the  use 
of  the  mercurial  in- 
unction as  applied 
in  syphilis.  Beneath 
the  skin  and  super- 
ficial fascia?  is  the 
axillary  fascia,  and 
beyond  this  dense 
membrane  is  the 
axillary  space.  The 
connective  tissue 
with  which  the 
axillary  space  is 
mainly    occupied    is 

very  loose,  and,  while  this  laxity  favours  greatly  the 
free  movement  of  the  arm,  it  at  the  same  time  permits 
of  the  formation  of  large  purulent  collections  and 
immense  extravasations  of  blood. 

It  is  important  to  remember  the  disposition  of  the 
fasciae  about  this  region.  There  are  three  layers 
principally    concerned.     (1)  The    deep    pectoral    fascia 


ig.  25.— Vertical  Sect  ion  through  the  Asilla 
and  Shoulder-joint    (Rudinger). 

Scapula;  2,  humerus;  •",  clavicle;  4,  acromion  : 
«,  trapezius;  b,  supraspinatus ;  c,  subacromial 
bursa  and  deltoid;  <i,  circumflex  artery  and 
nerve  ;  e.latissimusdorsi  ;  /.  coraco-bracbialis 

and    biceps;   p,  subscapuiaris ;     h,    serratus 
mngnns;  f, axiUarj  nrterj  ■  j,  axillary  vein. 


204  Surgical  Applied  Anatomy,     tchap.  xi. 

that  covers  in  and  encloses  the  pectoralis  major. 
(2)  The  clavi-pectoral  fascia  that,  adherent  above  to 
the  clavicle,  fills  in  the  space  between  that  bone  and 
the  pectoralis  minor,  then  splits  to  invest  this  muscle, 
and  joins  the  deep  pectoral  layer  at  the  anterior  fold 
of  the  axilla  to  form  with  it  the  axillary  fascia.  The 
upper  part  of  this  fascia  is  generally  known  as  the  costo- 
coracoid  membrane.  The  whole  membrane  is  sometimes 
known  also  as  the  "  suspensory  ligament  of  the  axilla," 
since  it  draws  up  the  axillary  fascia  towards  the  clavicle, 
and  is  mainly  instrumental  in  producing  the  "  hollow  " 
of  the  armpit.  (3)  The  axillary  fascia  that  is  formed 
by  the  union  of  the  two  preceding  fasciae,  and  stretches 
across  the  base  of  the  axilla  from  its  anterior  to  its  pos- 
terior fold.     It  is  thinnest  under  the  axillary  hairs. 

Abscess  about  the  axillary  region  may  be 
considered  (1)  when  it  is  beneath  the  pectoralis  major, 
or  between  the  two  pectoral  muscles,  and  (2)  when  it  is 
beneath  the  pectoralis  minor  and  clavi-pectoral  fascia, 
and  therefore  in  the  axillary  space.  (1)  An  abscess 
in  this  situation  is  placed  between  the  deep  pectoral 
and  the  clavi-pectoral  fascise,  the  latter  separating  it 
from  the  axillary  space.  Such  an  abscess  undermines 
the  great  pectoral,  and  tends  to  present  either  at  the 
anterior  margin  of  the  axilla,  or  in  the  groove  between 
the  great  pectoral  and  deltoid  muscles,  being  guided 
thither  by  the  attachment  of  the  fascia?.  (2)  A  puru- 
lent collection  in  the  axilla  may  soon  fill  that  space  and 
distend  it  entirely.  Its  progress  towards  the  skin  is 
arrested  by  the  axillary  fascia,  its  progress  backwards 
by  the  serratus  magnus  muscle,  which,  by  its  attachment 
to  the  scapula,  . hermetically  closes  the  axillary  space 
behind.  In  front  the  advance  of  the  abscess  is  prevented 
by  the  pectoral  muscles  and  clavi-pectoral  fascia,  while 
on  the  inner  side  is  the  unyielding  thorax,  and  on  the 
outer  side  the  upper  limb.  The  abscess,  therefore, 
as  it  fills  the  axilla  pushes  forwards  the  pectoralis  major, 
more  or  less  obliterates  the  hollow  of  the  armpit,  thrusts 
back  the  scapula,  and  widens  the  angle  between  the 
serratus  magnus  and  the  subscapularis  muscles.     There 


Chap,  xi.]    The  Region  of  the  Shoulder.  205 

is  a  great  tendency,  therefore,  for  unrelieved  abscesses 
to  extend  upwards  into  the  neck,  that  being  the  direction 
in  which  the  least  amount  of  resistance  is  encountered. 
From  the  neck  the  purulent  collection  may  extend 
into  the  mediastinum.  In  one  case  an  axillary  abscess, 
set  up  by  shoulder-joint  disease,  perforated  the  first 
intercostal  space  and  set  up  fatal  pleurisy 

In  opening  an  axillary  abscess,  and,  indeed,  in  most 
incisions  into  this  space,  the  knife  should  be  entered 
at  the  centre  of  the  floor  of  the  axilla,  i.e,  midway 
l)etween  the  anterior  and  posterior  margins,  and  near 
to  the  inner  or  thoracic  side  of  the  space.  The  vessels 
most  likely  to  be  damaged  by  an  indiscreet  incision 
are  the  subscapular,  running  along  the  lower  border 
of  the  subscapularis  muscle  ;  the  long  thoracic,  following 
the  lower  border  of  the  small  pectoral ;  and  the  main 
vessels  lying  close  to  the  humerus.  The  knife,  if  properly 
entered,  should  be  midway  between  the  two  first-named 
vessels,  and  quite  away  from  the  main  trunks.  There 
is  an  artery  (the  external  mammary)  that  sometimes 
comes  off  as  the  lowest  branch  of  the  axillary  trunk, 
and  crosses  the  middle  of  the  axilla,  to  be  distributed 
to  the  thorax  below  the  long  thoracic.  This  vessel 
would  probably  be  wounded  in  the  incision  above  named. 
The  artery  is,  however,  very  inconstant,  is  small,  and 
is  not  far  below  the  surface.  It  is  usually  met  with 
in  female  subjects. 

Lymphatic  glands. — The  axillary  glands  are 
numerous,  and  of  much  surgical  importance.  They 
may  be  arranged  in  four  sets.  (1)  The  greater  number 
are  placed  to  the  inner  side  of  the  axillary  vein  beneath 
the  axillary  tuft  of  hair.  This  central  set  of  glands 
receives  the  lymph  from  the  upper  extremity  and  breast. 
Pain  in  the  axilla  which  follows  whitlow  or  any  septic 
infection  of  the  arm  is  due  to  inflammation  of  this 
group,  which  is  pierced  by  the  inter-costo-humeral  nerve. 
(2)  The  deep  axillary  set  lies  along  the  axillary  vessels. 
It  receiver  the  lymph  from  the  central  set  and  become-: 
continuous  with  the  lower  deep  cervical  glands  in  the 
subclavian  triangle  (Fig.  21,  p.  164).    (3)  Other  glands  lie 


206  Surgical  Ajpplied  Anatomy.     {Chap. xi. 

upon  the  serratus  magnus  muscle  on  the  thoracic  side- 
of  the  axilla,  and  just  behind  the  lower  border  of  the 
pectoral  muscles.  They  receive  the  lymphatics  from 
the  front  of  the  chest,  the  principal  lymph  vessels  of 
the  breast,  and  the  superficial  lymphatics  of  the  abdomen, 
as  low  down  as  the  umbilicus.  Their  efferent  vessels 
for  the  most  part  pass  on  to  join  the  central  set  of  glands. 
These  glands  will  be  the  first  to  be  enlarged  in  certain 
breast  affections,  and  after  blistering  and  other  super- 
ficial inflammations, etc.,  of  the  chest  and  upper  abdomen. 
Paulet  has  seen  them  affected  in  inflammation  of  the 
hand.  The  axillary  process  of  the  female  breast  is  in 
contact  with  this  set.  (4)  The  remaining  glands  are 
situated  at  the  back  of  the  axilla,  along  the  subscapular 
vessels.  They  are  joined  by  the  lymphatics  from  the 
back. 

It  may  here  be  convenient  to  note  that  one  or  two 
glands  are  commonly  found  in  the  groove  between  the 
deltoid  and  pectoralis  major  muscles.  They  receive 
some  vessels  from  the  outer  side  of  the  arm  and  a  part 
of  the  shoulder  and  breast.  The  superficial  lymphatics 
over  the  upper  part  of  the  deltoid  go  to  the  cervical 
glands  (Tillaux),  over  the  lower  half  to  the  axilla.  The 
lymphatics  from  the  supraspinous  fossa  follow  the 
suprascapular  artery,  and  join  the  lowest  cervical  glands. 
The  superficial  lymphatics  of  the  back  that  converge 
to  the  axilla  are  derived  from  the  neck  over  the  trapezius 
muscle,  and  from  the  whole  dorsal  and  lumbar  regions 
as  far  down  as  the  iliac  crest. 

The  complete  removal  of  axillary  glands  is  an  opera- 
tion frequently  undertaken.  It  will  be  understood 
from  their  position  that  these  bodies,  when  diseased, 
are  very  apt  to  become  adherent  to  the  axillary  vessels, 
and  especially  to  the  vein.  The  latter  vessel  has  fre- 
quently been  wounded  or  excised  during  the  removal 
of  gland  tumours,  and  in  one  case  at  least  the  artery 
was  accidentally  cut  (Holmes). 

The  axillary  vessels. — The  axillary  vein  is 
formed  by  the  union  of  the  basilic  with  the  two  vense 
comites  of  the  brachial  artery.     This  union  commonly 


Chap,  xi.]    The  Region  of  the  Shoulder.  207 

takes  place  at  the  lower  border  of  the  subscapular  muscle, 
and  the  vein  is  therefore  shorter  than  the  artery.  Some- 
times the  vein  does  not  exist  as  a  single  trunk  until 
just  below  the  clavicle.  This  condition,  when  it  exists, 
is  very  unfavourable  to  operations  upon  the  artery, 
OS  many  transverse  branches  cross  that  vessel  to  unite 
the  veins  that  lie  on  either  side  of  it.  The  axillary  vein. 
b?ing  comparatively  near  the  heart,  is  readily  influenced 
as  regards  its  contained  blood  by  the  inspiratory  move- 
ment. Thus  it  happens  that  in  many  instances  of  wound 
of  the  vessel,  or  of  its  larger  tributaries,  air  has  been 
drawn  into  the  venous  canal  and  death  has  ensued. 
The  entrance  of  air  into  the  main  vein  is  perhaps  aided 
by  the  circumstance  that  the  costo-coracoid  membrane 
(upper  part  of  clavi-pectoral  fascia)  is  adherent  to  the 
vessel,  and  thus  tends  to  maintain  it  in  a  patent  con- 
dition when  wounded.  This  connection  with  the  fascia 
is  supposed  by  some  to  account  in  part  for  the  furious 
bleeding  that  occurs  from  this  vein  when  it  is  divided. 

The  vein  is  more  often  wounded  than  is  the  artery, 
it  being  larger,  more  superficial,  and  so  placed  as  to  more 
or  less  overlap  the  arterial  trunk.  On  the  other  hand. 
in  injury  to  the  vessel  by  traction,  as,  for  example,  in 
reducing  dislocations,  the  artery  suffers  more  frequently 
than  the  vein.  In  all  positions  of  the  upper  limb  the 
artery  keeps  to  the  outer  angle  of  the  axillary  space. 
The  relation  of  the  vein,  however,  to  the  first  part  of 
the  axillary  artery,  the  part  above  the  pectoralis  minor, 
is  modified  by  the  position  of  the  limb.  Thus,  when 
the  arm  hangs  by  the  side  the  vein  is  to  the  inner  side 
of  the  artery,  and  a  little  in  front  of  it,  but  when  the 
limb  is  at  a  right  angle  with  the  trunk  the  vein  is  drawn 
so  far  in  front  of  the  artery  as  to  almost  entirely  conceal 
that  vessel. 

Aneurism  is  very  frequent  in  the  axillary  artery, 
a  fact  to  be  explained  by  the  nearness  of  the  vessel  to 
the  heart,  by  the  abrupt  curve  it  presents,  by  its  suscepti- 
bility to  frequent  and  extensive  movements,  and  by 
its  liability  to  share  in  the  many  lesions  of  the  upper 
limb.     In  violent  and  extreme  movements  of  the  limb 


2oS  Surgical  Applied  Anatomy.     [Chap.  xi. 

the  artery  may  be  more  or  less  torn,  especially  if  its 
walls  are  already  diseased. 

In.  ligaturing  the  first  part  of  the  axillary  artery 
it  is  well  to  note  that  the  pectoralis  major  has  some- 
times a  cellular  interval  between  two  planes  of  muscle 
fibre,  and  this  may  be  mistaken  for  the  space  beneath 
it  (Heath).  If  the  pectoralis  minor  has  an  origin  from 
the  second  rib,  it  may  more  or  less  entirely  cover  the 
artery  and  require  division.  The  cord  of  the  brachial 
plexus  nearest  to  the  artery  may  be  mistaken  for  that 
vessel,  or  easily  included  in  a  ligature  intended  for  it. 
A  ready  guide  to  the  axillary  vessels  in  this  operation 
is  to  follow  the  cephalic  vein.  The  anterior  internal 
thoracic  nerve  appears  between  the  vein  and  artery 
as  it  passes  to  the  pectoralis  minor.  It  also  may 
be  useful  occasionally  as  a  guide. 

In  applying  a  ligature  to  the  third  part  of  the  artery, 
it  should  be  borne  in  mind  that  a  muscular  slip  some- 
times crosses  the  vessels  obliquely,  passing  from  the 
latissimus  dorsi  to  join  the  pectoralis  major,  coraco- 
brachialis,  or  biceps  muscles.  This  slip  may  give  rise 
to  confusion  during  the  operation,  and  may  be  mistaken 
for  the  coraco-brachialis. 

The  axillary  nerves. — Any  of  the  axillary 
nerves  may  be  injured  by  a  wound,  the  median  being 
the  most  frequently  damaged,  and  the  musculo-spiral 
the  least  frequently.  The  comparative  immunity  of 
the  latter  is  explained  by  its  deep  position,  its  situation 
at  the  inner  and  posterior  aspect  of  the  limb,  and  its  large 
size.  The  nerves  are  very  seldom  torn  by  a  traction 
on  the  limb  short  of  more  or  less  complete  avulsion. 
Indeed,  if  forcibly  stretched,  they  are  disposed  rather 
to  become  torn  away  from  their  attachments  to  the 
spinal  cord  than  to  give  way  in  the  axilla.  Thus, 
Flaubert  records  a  case  where  the  last  four  cervical 
nerves  were  torn  away  from  the  cord  during  a  violent 
attempt  to  reduce  a  dislocated  shoulder. 

The  deltoid  region. — This  region,  comprising 
as  it  does  the  "  point "  of  the  shoulder,  is  limited  in 
all   parts   by  the   deltoid  muscle.     The   deltoid   covers 


fchap.  xi.]    The  Reg/on  of  the  Shoulder.  209 

the  upper  end  of  the  humerus  and  the  shoulder  joint. 

Between  the  joint  and  the  surface,  therefore,  are  only 
the  skin  and  superficial  fascia,  the  deltoid  in  its  sheath, 
and  some  loose  connective  tissue  (the  subdeltoid  tissue) 
in  which  is  found  the  great  subacromial  bursa.  This 
subdeltoid  tissue  sometimes  assumes  the  form  of  a 
distinct  thick  membrane,  and  may  have  an  important 
influence  upon  the  localisation  of  purulent  collections 
proceeding  from  the  joint.  The  fatty  tissue  over  the 
deltoid  is  a  favourite  seat  for  lipomata,  and  it  is  in  this- 
situation  that  the  tendency  of  these  growths  to  change 
their  position  is  sometimes  seen.  Thus,  Erichsen  records 
a  case  where  the  tumour  slid  downwards  from  the 
shoulder  to  the  breast. 

b  Emerging  from  the  interval  between  the  two  teres 
muscles,  and  winding  horizontally  round  the  shaft  of 
the  humerus,   quite  close  to  the  bone,  and  about  the 
line  of  the  surgical  neck,  are  the  circumflex  nerve  and 
posterior    circumflex    artery.     This    nerve    affords    an 
example  of  an  arrangement  pointed  out  by  Mr.  Hilton. 
viz.,  that  a  principal  nerve  to  a  joint  not  only  supplies 
the  articular  surfaces,  but  also  some  of  the  main  muscles 
that  move  that  joint  and  the  skin  over  those  muscles. 
This  nerve  supplies  the  shoulder  joint,  the  deltoid  and 
teres  minor  muscles,  and  the  skin  over  the  lower  two- 
thirds  of  the  shoulder  and  upper  part  of  the  triceps. 
"  The   object   of  such   a   distribution   of   nerves   to   the 
muscular  and  articular  structures  of  a  joint,  in  accurate 
association,  is  to  ensure  mechanical  and    physiological 
consent     between    the    external    muscular    or    moving 
force  and  the  vital  endurance  of  the  parts  moved,  viz,, 
of  the  joints,  thus  securing  in  health  the  true  balance 
of  force  and  friction  until  deterioration  occurs  "  (Hilton). 
This   nerve   is   frequently  damaged  in  injuries   to   the 
shoulder.     It  may  be  severely  bruised  by  a  simple  con- 
tusion of  the  part,  and  this  bruising  may  be  followed 
by  paralysis  of  the  deltoid.     It  would  appear,  however, 
that  damage  to  the  circumflex  is  much  less  frequent 
after   contusions   of   the   shoulder   than    was   formerly 
maintained.     It   will   also   be    readilv   understood    that 


210  Surgical  Applied  Anatomy.      [Chap. Xi. 

the  nerve  is  often  torn  in  fractures  of  the  surgical  neck 
of  the  humerus,  in  dislocations  of  that  bone  (especially 
the  luxation  backwards),  and  in  violent  attempts  at 
reducing  Vich  dislocations.  The  nerve,  from  its  position, 
is  very  apt  to  be  seriously  pressed  upon  by  growths 
springing  from  the  upper  end  of  the  humerus.  From 
its  connection  with  the  joint,  it  follows  that  in  chronic 
inflammation  of  that  part  the  inflammation  may  extend 
along  the  nerve,  producing  a  neuritis  that  may  lead 
to  paralysis  of  the  deltoid  (Erb). 

The  shoulder-joint. — From  one  surgical  point 
of  view,  joints  may  be  divided  into  (1)  those  that  depend 
for  their  strength  mainly  upon  ligaments  ;  (2)  those 
that  are  mechanically  strong,  and  that  derive  their 
stability  to  a  great  extent  from  the  arrangement  of 
their  component  bones  ;  and  (3)  those  that  rely  for 
their  support  principally  upon  muscles.  As  an  example 
of  the  first  kind  may  be  cited  the  sterno-clavicular 
joint,  of  the  second  form  the  elbow-joint,  and  of  the 
third  the  shoulder-joint.  The  articulation  the  least 
prone  to  dislocation  is  the  one  that  derives  its  strength 
from  tough  unyielding  ligaments,  while  the  one  most 
often  luxated  belongs  to  the  third  variety,  its  strength 
being  greatly  dependent  upon  muscles  that  may  be  taken 
by  surprise,  and  that  may  themselves,  from  disordered 
action,  prove  sources  of  weakness.  These  are,  of  course, 
not  the  only  features  in  the  etiology  of  dislocation. 
A  great  deal  depends  upon  the  amount  of  movement 
permitted  in  a  given  joint,  and  the  degree  of  leverage 
that  can  be  brought  to  bear  upon  its  parts, 

i  The  arch  formed  by  the  coracoid  and  acromion 
processes  and  the  ligament  between  them  forms  an 
essential  support  'to  the  head  of  the  humerus,  and  is 
an  important  constituent  of  the  articulation.  With 
this  arch  the  humeral  head  is  in  immediate  relation, 
though  not  in  actual  contact  (Fig. 25,  p.  203).  In  paralysis 
of  the  deltoid  the  head  may  be  separated  by  some  distance 
from  the  coracoid  process,  and  Nannoni  records  the 
case  of  a  child  with  old-standing  paralysis  of  the  deltoid, 
between  whose  humeral  head  and  acromial  vault  four 


Chap,  xi.]    The  Region  of  the  Shoulder.  211 

fingers  could  be  lodged.  It  is  well  to  note  that  at  least 
two-thirds  of  the  head  of  the  bone  are  not  in  contact 
with  the  glenoid  cavity  when  the  arm  hangs  by  the 
side,  and  Anger  points  out  that  in  this  position  three- 
fourths  of  the  circumference  of  the  humeral  head  are 
in  front  of  a  vertical  line  drawn  from  the  anterior  border 
of  the  acromion  process.  In  this  posture,  also,  the 
head  is  wholly  to  the  outer  side  of  the  coracoid  process. 
The  margin  of  the  glenoid  cavity  is  more  prominent 
on  the  inner  than  on  the  outer  side,  while  the  strongest 
part  of  the  margin  and  the  broadest  part  of  the  fossa 
are  below.  This  is  significant,  since  it  points  to  an 
attempt  to  strengthen  a  part  of  the  joint  that  practice 
shows  to  be  the  weakest  in  the  articulation,  viz.,  the 
lower  and  inner  portion  of  the  capsule.  It  is  at  this 
place  that  the  head  of  the  bone  leaves  the  joint  in 
dislocation  of  the  shoulder. 

The  capsule  of  the  shoulder-joint  is  very  lax,  and 
would  lodge  a  bone-head  twice  as  large  as  that  of  the 
humerus.  According  to  Henry  Morris,  no  one  part 
of  the  capsule  is  constantly  thicker  than  the  rest,  us 
is  the  case  in  the  hip-joint.  The  inner  part  of  the 
capsule  looks  into  the  axilla,  and  is  there  free  between 
the  two  tuberosities,  between  the  lesser  one  in  front 
and  the  posterior  part  of  the  greater  one  behind. 
It  is  between  these  two  projections  that  the  humeral 
head  can  be  felt  through  the  axilla. 

Of  the  bursa  about  the  joint,  the  subacromial  bursa 
is  the  one  most  frequently  the  seat  of  disease.  This  sac, 
when  distendedwith  fluid,  maybe  mistaken  for  the  results 
of  chronic  inflammation  of  the  joint  (Fig.  25,  p.  203). 

Experiment  shows  that  the  walls  of  this  bursa  may 
be  actually  torn  in  twists  of  the  arm,  especially  when 
either  flexed  or  extended  (Nancrede).  When  the  sac 
is  distended  most  pain  is  elicited  in  the  position  of  abduc- 
tion, for  in  this  posture  the  bursal  walls  are  normally 
folded  up,  so  as  to  form  a  sort  of  collar  in  advance  of 
the  greater  tuberosity.  When  the  walls  are  thickened 
and  distended  by  inflammation,  abduction  must  press  the 
bursa  very  forcibly  under  the  acromion,  and  so  cause 


2i2  Surgical  Applied  Anatomy.     [Ciiap.  xi. 

pain.  In  elderly  people  the  sac  sometimes  communicates 
with  the  joint.  The  subscapular  bursa  is  in  free  com- 
munication with  the  capsule  of  the  joint  in  front. 

The  biceps  tendon  strengthens  the  upper  part 
of  the  joint,  keeps  the  humerus  against  the  glenoid 
cavity  in  the  various  positions  of  the  limb,  and  pre- 
vents the  head  of  the  bone  from  being  pulled  too  closely 
upwards  under  the  acromion.  The  tendon  may  be 
ruptured,  and  in  such  a  case,  in  addition  to  the  general 
weakening  of^the  limb,  and  the  peculiar  projection 
formed  by  the  "contraction  of  the  muscle,  the  head  of  the 
humerus  is  usually  drawn  upwards  and  forwards  until 
arrested  by  the  coraco-acromial  arch.  Thus,  a  kind 
of  slight  false  dislocation  may  be  produced.  In  certain 
violent  wrenches  of  the  limb  the  tendon  may  slip  from 
its  groove  and  be  displaced  to  one  or  other  side,  usually 
to  the  inner  side.  In  these  cases  also  the  head  is  drawn 
up  under  the  acromion,  and  is  prominent  in  front, 
while  abduction  is  rendered  less  free  than  is  normal 
owing  to  the  great  tuberosity  being  sooner  brought  in 
contact  with  the  acromion.  The  intracapsular  part 
of  the  tendon  may  disappear  in  cases  of  chronic  rheu- 
matic arthritis,  owing  to  friction  against  the  abraded 
articular  surface  of  the  humerus.  It  acquires  an  attach- 
ment to  the  bicipital  groove  in  such  cases. 

Joint  disease. — This  articulation  is  liable  to  all 
forms  of  joint  disease.  The  capsule,  as  just  stated, 
is  very  lax,  but  the  humerus  is  kept  in  contact  with 
the  glenoid  cavity  by  muscular  and  atmospheric 
pressure.  In  joint  disease,  however,  the  effusion 
may  effect  a  considerable  separation  of  the  two 
bones.  Braune,  having  pierced  the  glenoid  cavity 
through  the  supraspinous  fossa,  injected  tallow  at 
considerable  pressure  into  the  joint.  When  fully 
distended  the  humerus  was  found  to  be  separated 
from  the  scapula  by  more  than  \  an  inch,  and  this 
may  serve  to  explain  the  lengthening  of  the  limb 
often  noted  in  joint  disease  of  this  part  with  much 
effusion.  When  the  greatest  degree  of  distension  of 
the  capsule  was  reached  the  humerus  became  slightly 


chap,  xi.]    The  Region  of  the  Shoulder.  215 

extended  and  rotated  in.  It  is  significant  that  in 
shoulder-joint  disease  it  is  common  for  the  arm  to  be 
found  close  to  the  side,  the  elbow  carried  a  little  back 
(extension),  and  the  limb  rotated  inwards.  This  position 
may  also  be  due  to  the  rigid  contraction  of  the  muscles 
about  the  joint  that  is  usually  observed.  When  such 
contractions  exist  it  may  be  inferred  that  the  powerful 
latissimus  dorsi  has  a  little  advantage  over  its  opponents, 
and  may  be  answerable  for  the  rotation  in  and  slight 
projection  backwards  of  the  arm.  The  inner  part  of 
the  epiphyseal  cartilage  is  just  within  the  capsule,  the 
outer,  anterior,  and  posterior  parts  are  entirely  sub- 
periosteal. It  happens,  therefore,  that  the  pus  in  sup- 
purative epiphysitis  will  find  its  way  into  the  joint. 
There  may  be  three  diverticula  from  the  synovial 
membrane  :  (1)  One  that  runs  some  way  down  the 
bicipital  groove  with  the  tendon;  (-2)  a  cul-de-sac 
beneath  the  subscapulars,  formed  by  a  communication 
between  the  synovial  cavity  and  the  bursa  under  that 
muscle  ;  and  (3)  a  cul-de-sac  of  like  nature  beneath 
the  infraspinatus  muscle.  The  first-named  is  constant  ; 
the  second  is  frequently  present ;  the  third  is  rare. 
When  the  joint  is  filled  with  effusion,  the  capsule  is 
evenly  distended  and  the  shoulder  evenly  rounded. 
Special  projections  usually  occur  at  the  seats  of  the 
diverticula.  Thus  a  swelling  often  appears  early  in 
the  course  of  a  synovitis  in  the  groove  between  the 
pectoralis  major  and  the  deltoid  muscles,  and  this 
swelling  may  appear  bilobed,  being  cut  in  two  by  the 
unyielding  biceps  tendon  (Paulet).  Fluctuation  can 
best  be  felt  by  examining  the  uncovered  part  of  the 
capsule  in  the  axilla  beyond  the  subscapular  muscle. 
When  the  joint  suppurates  pus  usually  escapes  at  one 
of  the  culs-dc-sac  just  mentioned,  most  often  through 
the  one  that  follows  the  biceps  tendon.  Pus  may  thus 
extend  for  some  way  along  the  bicipital  groove.  Pus 
escaping  through  the  subscapular  cul-de-sac  is  apt  to 
spread  between  the  muscle  and  the  venter  of  the  scapula, 
and  to  present  at  the  lower  and  back  pari  of  the  axilla. 
Purulent    collections    beneath    the    deltoid    are    rearlv 


214  Surgical  Applied  A  a  atomy.     [Chap.  xi. 

always  conducted  towards  the  anterior  aspect  of  the 
limb,  being  unable  to  proceed  backwards  owing  to  the 
denseness  of  the  fascia  covering  in  the  deltoid  and  infra- 
spinous  muscles.  In  one  recorded  case,  pus  that  had 
escaped  from  the  shoulder-joint  followed  the  course  of 
the  musculo-spiral  nerve,  and  opened  on  the  outer  side 
of  the  elbow. 

The  various  forms  of  anchylosis  are  common  at  the 
shoulder-joint,  and  to  afford  a  freer  range  of  move- 
ment to  the  limb  in  the  more  intractable  of  these  cases, 
Tillaux  proposes  to  divide  the  clavicle. 

Dislocations. — Dislocations  at  this  joint  are 
more  common  than  at  any  other  joint  in  the  body.  This 
is  explained  by  the  shallowness  of  the  glenoid  fossa, 
the  large  size  and  globular  shape  of  the  head  of  the 
humerus,  the  extensive  movements  of  the  arm,  the 
long  leverage  it  affords,  and  the  dependence  of  the  articu- 
lation for  its  strength  mainly  upon  muscles.  The  upper 
limb  and  shoulder  are  also  peculiarly  exposed  to  injury. 

The  principal  forms  of  luxation  of  the  humerus  at 
the  shoulder  are  :  1.  Subcoracoid,  forwards  and  a  little 
downwards ;  the  usual  form.  2.  Subglenoid,  down- 
wards and  a  little  forwards ;  rare.  3.  Subspinous, 
backwards  ;  rare. 

In  all  complete  dislocations  the  head  of  the  bone 
leaves  the  joint  cavity  through  a  rent  in  the  capsule. 
In  so-called  "  false  luxations  "  the  capsule  is  not  torn. 
For  example,  in  the  cadaver,  if  the  deltoid  be  divided 
the  humeral  head  can  be  displaced  under  the  coracoid 
process  without  rupture  of  the  capsule,  and  the  same 
thing  may  occur  during  life,  in  cases  where  the  muscle 
has  long  been  paralysed. 

In  all  cases  of  dislocation  at  this  joint  the  primary 
displacement  is  always  downwards  into  the  axilla.  It 
is  well  known  that  dislocations  at  the  shoulder  are 
usually  due  to  violence  applied  to  the  limb  while  the 
arm  is  abducted,  or  to  severe  direct  violence  forcing 
the  bone  downwards.  Now  when  the  limb  is  abducted 
the  head  of  the  humerus  projects  below  the  glenoid  fossa, 
and   rests  upon  the  inferior  and  least  protected  part 


Chap,  xi.]    The  Region  of  the  Shoulder.  215 

of  the  capsule.  The  fibres  of  this  portion  of  the  capsule 
being  tightly  stretched  in  this  position,  it  requires  no 
extraordinary  force  to  tear  the  ligament  and  drive  the 
bone  into  the  axilla. 

Thus  it  happens  that  in  luxations  at  this  joint  the 
rent  in  the  capsule  is  at  its  inferior  and  inner  aspect. 
The  head  of  the  bone  being  thus  driven  downwards 
into  the  axilla,  may,  for  certain  reasons,  remain  there 
(subglenoid  form),  or  more  usually  it  will  be  drawn 
forwards  and  inwards  by  the  powerful  pectoralis  major, 
aided  by  other  muscles  whose  action  is  now  less  resisted 
and  by  the  weight  of  the  unsupported  limb  (subcoracoid 
form) ;  and  lastly,  the  direction  of  the  violence  being 
applied  markedly  from  in  front,  the  head  of  the  bone 
may  be  thrust  backwards  under  the  acromion  or  spinous 
processes  (subspinous  form).  The  overwhelming  fre- 
quency of  the  subcoracoid  variety  is  explained  by  the 
greater  advantage  at  which  those  muscles  act  that 
draw  the  bone  forwards,  in  comparison  with  those  that 
would  draw  it  backwards,  and  by  the  very  trifling  opposi- 
tion offered  to  the  passage  of  the  head  forwards  when 
compared  with  the  substantial  obstacles  in  the  way  of  its 
passage  backwards  under  the  scapular  spine. 

Features  common  to  all  dislocations  at 
the  shoulder.— As  the  roundness  of  the  deltoid 
depends  to  a  great  extent  upon  the  presence  beneath 
it  of  the  humeral  head,  and  as  in  all  these  luxations 
(save  perhaps  in  the  slighter  grades  of  the  subspinous 
form)  the  head  is  removed  practically  from  its  connection 
with  the  deltoid,  that  muscle  is  always  more  or  less 
flattened.  This  flattening  is  augmented  by  the 
stretching  of  the  muscle,  which  in  some  degree  is  con- 
stantly present.  Stretching  of  the  deltoid  involves 
abduction  of  the  arm,  and  this  symptom  is  fairly  constant 
in  all  the  luxations.  The  biceps  being  also  more  or  less 
unduly  tense,  the  elbow  is  found  flexed  and  the  fore-arm 
supinated.  In  every  form  there  is  some  increase  in 
the  vertical  circumference  of  the  axilla,  since  the  head, 
having  left  the  glenoid  fossa,  must  occupy  some  part 
comprised  within  that  circumference.    Again, Dr, Dugas 


2  1 6  Surgical  Applied  Anatomy.      [Chap.  xi. 

"has  pointed  out  that  "  if  the  fingers  of  the  injured 
limb  can  be  placed  by  the  patient,  or  by  the  surgeon, 
upon  the  sound  shoulder  while  the  elbow  touches  the 
ithorax  (a  condition  that  obtains  in  the  normal  condition 
of  the  joint),  there  can  be  no  dislocation ;  and  if  this 
cannot  be  done  there  must  be  one,  for  no  other  injury 
•than  a  dislocation  can  induce  this  physical  impossibility." 
This  depends  upon  the  fact  that  in  consequence  of  the 
rotundity  of  the  thorax  it  is  impossible  for  both  ends 
of  the  humerus  to  touch  it  at  the  same  time,  and  in 
luxation  at  the  shoulder  the  upper  end  of  the  bone 
is  practically  touching  the  trunk.  Lastly,  from  the 
position  of  the  great  vessels  and  nerves  it  will  be  seen 
that  in  the  subcoracoid  and  subglenoid  luxations  the 
head  of  the  bone  may  press  injuriously  upon  those 
structures.  Thus  may  result  oedema  of  the  limb  and 
severe  pain  or  loss  of  muscular  power.  The  artery 
is  usually  saved  by  its  greater  elasticity ;  but  Berard 
reports  a  case  of  displacement  forwards  where  the  axillary 
artery  was  so  compressed  by  the  humeral  head  as  to 
induce  gangrene  of  the  limb. 

The  close  connection  of  the  circumflex  nerve  with 
the  humerus  renders  it  very  liable  to  injury,  especially 
in  the  subglenoid  and  subspinous  forms  of  dislocation. 

Special  anatomy  of  each  form. — 1.  Sub- 
coracoid.— The  articular  head  of  the  humerus  lies  on 
the  anterior  surface  of  the  neck  of  the  scapula,  and 
the  anatomical  neck  rests  on  the  anterior  lip  of  the 
glenoid  fossa,  The  head  is  thus  placed  immediately 
below  the  coracoid  process,  and  is  in  front  of,  internal 
to,  and  a  little  below,  its  normal  site.  The  great 
tuberosity  faces  the  empty  glenoid  cavity  (Fig.  26). 
The  subscapulars  muscle  is  stretched  over  the  head 
of  the  humerus,  and  is  usually  in  some  part  torn.  The 
supraspinatus,  infraspinatus,  and  teres  minor  are 
stretched  or  torn,  or  the  great  tuberosity  may  even 
be  wrenched  off.  The  coraco-brachialis  and  short 
head  of  the  biceps  are  tense,  and  are  immediately  in 
front  of  the  head  of  the  humerus  instead  of  to  its  inner 
side.     The  long  tendon  of  the  biceps  is  deflected  down- 


Chap.  XL]    The  Region  of  the  Shoulder. 


217 


wards  and  outwards.  It  is  sometimes,  although  rarely, 
torn  from  its  groove.  The  deltoid  is  put  upon  the 
stretch.  The  prominence  formed  by  the  numeral 
head  in  the  front  of  the  axilla  depends  to  some  degree 
upon  the  amount  of  rotation.  If  the  bone  be  rotated 
out  the  projection  is  most  distinct;  but  if  rotated 
in,  its  head  sinks  into  the  axilla  and  is  brought  more 
in  contact  with  the 
scapula  than  with 
the  skin.  The  head 
of  the  bone  being  al- 
ways carried  a  little 
downwards,  some 
lengthening  must  in 
all  cases  really  exist ; 
but  with  the  ordin- 
ary method  of 
measuring  the  limb 
this  lengthening 
may  be  replaced  by 
a  normal  measure- 
ment, or  even  by 
apparentshortening. 
if  the  head  of  the 
bone  be  carried  a 
good  deal  forwards 
and  inwards,  and 
thelimb  be  abducted. 
When  the  head  has 
left  the  glenoid 

cavity  abduction  tends  to  bring  the  external  condyle 
nearer  to  the  acromion,  and  these  are  the  two  points 
between  which  the  measurement  is  usually  taken. 
Thus  the  apparent  length  of  the  arm  depends  mainly 
upon  the  degree  of  abduction  of  the  humerus,  or  the 
obliquity  of  the  axis  of  the  bone. 

2.  Subglenoid.-- -The  head  is  below,  and  a  little 
in  front  of  and  internal  to,  its  normal  position.  It 
cannot  go  directly  downwards,  owing  to  the  situation 
of  the  long  head  of  the  triceps,  but  escapes  in  the  interval 


Fie.    20. 


-Subcoracoid  Dislocation  of  the 
Humerus. 


2i8  Surgical  Applied  Anatomy.      [Chap.  xi. 

between  that  muscle  and  the  subscapularis.  The 
articular  head  rests  on  the  anterior  aspect  of  the  tri- 
angular surface  just  below  the  glenoid  fossa  that  gives 
origin  to  the  triceps.  The  upper  border  of  the  great 
tuberosity  is  in  close  relation  with  the  lower  margin 
of  the  joint.  It  is  generally  stated,  on  the  authority 
of  Malle,  that  the  circumstance  which  prevents  the 
head  of  the  bone  from  being  drawn  upwards  is  the 
entirety  of  the  anterior  part  of  the  capsule,  the  rent 
being  in  the  lower  part  only  of  that  ligament.  The 
subscapularis  muscle  is  much  stretched  or  torn,  and  the 
head  usually  lies  beneath  its  tendon,  and  upon  some 
fibres  of  the  disturbed  muscle.  The  supraspinatus 
will  be  torn.  The  infraspinatus  will  be  stretched  or 
torn,  and  the  two  teres  muscles  will  not  be  much  affected 
unless  there  be  considerable  abduction  of  the  arm. 
The  coraco-brachialis  and  biceps  will  be  stretched,  but 
owing  to  the  amount  of  abduction  usually  present 
the  biceps  tendon  is  but  little  deflected  from  a  straight 
line.  The  deltoid  is  greatly  stretched,  and  its  tension 
serves  to  produce  the  extreme  flattening  of  the  shoulder 
and  the  great  abduction  common  in  this  injury.  Some 
lengthening  is  seldom  absent,  although  it  is  always 
modified  by  the  abduction  that  exists. 

3.  Subspinous. — The  head  usually  rests  on  the 
posterior  surface  of  the  neck  of  the  scapula,  the  groove 
of  the  anatomical  neck  of  the  humerus  corresponding 
to  the  posterior  lip  of  the  glenoid  fossa.  The  head 
is  thus  placed  beneath  the  acromion  ;  but  it  may  be 
displaced  still  farther  back,  and  may  rest  on  the  dorsum 
scapulae,  and  beneath  the  scapular  spine  (Fig.  27). 
The  subscapularis  tendon  is  drawn  right  across  the 
glenoid  fossa,  and  is  often  torn  from  its  attachment. 
The  head  pushes  back  the  hinder  part  of  the  deltoid, 
the  infraspinatus  and  teres  minor  muscles.  These 
latter  cover  the  bone,  and  are  stretched  over  it.  The 
supraspinatus  is  tense,  as  is  also  the  biceps,  while  the 
teres  major  and  latissimus  dorsi  are  relaxed.  The 
great  pectoral  is  rendered  unduly  tense,  and  this  serves 
in  part  to  explain  the  rotation  inwards  of  the  humerus, 


chap,  xi.]    The  Region  of  the  Shoulder. 


2  10, 


and  the  adduction  forwards,  that  are  usually  observed, 
those  movements  being  more  or  less  unopposed.     The 
circumflex  nerve  is  often- 
torn. 

In  reducing  disloca- 
tions, especially  such  as 
are  of  long  standing, 
serious  damage  may  bo 
inflicted  on  the  axillary 
structures.  The  axillary 
artery  suffers  most  fre- 
quently, the  vein  rarely. 
and  the  nerves  still  less 
often.  The  artery,  being 
placed  externally,  is  apt 
to  contract  adhesions  to 
the  soft  parts  covering 
the  head  of  the  displaced 
bone,  and  to  be,  there- 
fore, torn  when  those 
parts  are  disturbed. 

Fractures  of  the 
upper    end    of    the 

humerus. — 1.  Anatomical  neck. — The  upper  part 
of  the  capsule  is  exactly  attached  to  the  anatomical 
neck,  and  in  this  situation  the  fracture  may  run  beyond 
the  ligament  and  be  partly  extracapsular.  The  lower 
part  of  the  capsule  is  inserted  some  little  way  below 
the  anatomical  neck,  and  in  this  position,  therefore, 
the  lesion  must  be  intracapsular.  From  the  line  of 
attachment  of  the  lower  part  of  the  capsule  to  the 
humerus,  fibres  are  reflected  upwards  to  the  margin 
of  the  articular  cartilage  on  the  head  of  the  bone.  These 
fibres,  if  unruptured,  may  serve  to  connect  the  frag- 
ments. If  entirely  separated,  the  head  of  the  bone 
must  necrose,  having  no  such  source  of  blood  supply 
as  the  head  of  the  femur  derives  from  the  round  ligament. 
It  is  easy  for  the  small  and  comparatively  dense  upper 
fragment  to  be  driveD  into  the  wide  surface  of  cancellous 
exposed od  the  upper  surface  of  the  lower  fragment. 


Fi£ 


—Subspinous    Dislocation    of 
the  Humerus. 


220  Surgical  Applied  Anatomy.      [Chap.  xi. 

When  impaction  occurs,  there  may  be  some  flattening 
of  the  deltoid,  since  the  head  is  rendered  of  less  dimensions 
by  that  impaction,  and  consequently  causes  a  less  pro- 
jection of  the  deltoid.  It  may  be  possible  to  detect 
the  impaction  by  examination  through  the  axilla  when 
the  arm  is  fully  abducted.  The  difficulty  of  obtaining 
crepitus  in  non-impacted  fractures  will  be  obvious 
when  the  small  size  of  the  upper  fragment  is  considered, 
together  with  its  great  mobility,  and  the  obstacles  in 
the  way  of  so  fixing  it  that  one  broken  end  may  be 
rubbed  against  the  other. 

The  amount  of  displacement  is  to  be  measured  by 
the  laxity  of  the  capsule.  The  usual  deviation  is  a 
projection  of  the  upper  end  of  the  lower  fragment  to- 
wards the  anterior  and  inner  side  of  the  articulation, 
brought  about  mainly  by  the  muscles  attached  to  the 
bicipital  groove.  In  no  case  could  the  two  bone-ends 
overlap. 

2.  Separation  of  the  upper  epiphysis. — The 
lower  border  of  this  epiphysis  is  represented  by  a  hori- 
zontal line  crossing  the  bone  at  the  base  of  the  great 
tuberosity  and  placed  between  the  anatomical  and 
surgical  necks.  It  would  be  fairly  indicated  by  a  trans- 
verse saw-cut  through  the  widest  part  of  the  bone. 
The  three  component  nuclei  of  this  epiphysis  (head, 
greater  and  lesser  tuberosities)  fuse  together  about  the 
fifth  year,  and  the  entire  mass  joins  the  shaft  about 
the  twentieth  year.  The  upper  fragment  may  be  carried 
and  rotated  a  little  outwards  by  the  muscles  attached 
to  the  great  tuberosity,  while  the  lower  fragment  is 
drawn  inwards  and  forwards  by  the  muscles  inserted 
into  the  bicipital  groove.  Thus,  a  part  of  the  smooth 
upper  end  of  the  lower  fragment  commonly  forms 
a  distinct  projection  below  the  coracoid  process.  In 
such  case  the  axis  of  the  limb  would  be  altered,  and 
the  elbow  carried  a  little  from  the  side.  Often,  how- 
ever, the  displacement  is  solely  in  the  antero-posterior 
direction,  the  lower  fragment  projecting  forwards.  So 
wide  are  the  two  bone  surfaces  at  the  seat  of  injury  that 
it  is  scarcely  possible  for  them  to  overlap  one  another. 


Chap.  XL;     The   Rl  7LDER. 


::  I 


Surgical  neck. — The  surgical  neck  is  situated 
between  the  bases  of  the  tuberosities  and  the  insertions 
of  the  latissirans  dor-i  and  teres  major  muscles.  A 
common  displacement  of  parts  is  the  following.  The 
upper  fragment  Is  carried  out  and  rotated  out  by  the 
supra-  and  infra-Bpinataa  and  teres  minor.  The  upper 
end  of  the  lower  fragment  is  drawn  upward-  by  the 


.    —a  ..j.utaiiou  a*.  Shonkter-joini  (flap-method)  ^Agatz). 

..■-id  cavity;  I,  deltoid  :   <:.  lima  head     .     ..-•.  -        ,  peel     _-.s  major;  e, 
bicepe  and  coracobrachial  -  -        -       --  ;,tricep«; 

l,  axillary  ves.-eli  :  ■:,  circumflex  vessels  ;  3.  brai.;. 

deltoid,  biceps,  coraco-braclnali<.  and  triceps,  inwards 
by  the  muscles  attached  to  toe  bicipital  groove,  and 
forwards  by  the  great  pectoral  Tims,  it  forms  a  pro- 
jection in  the  axilla,  and  the  axis  of  the  limb  is  altered 
so  that  the  elbow  projects  from  the  side.  This  displace- 
ment, however,  is  by  no  me.  stank  Pean.  A:.. 
and  others  maintain  that  the  usual  deformity  is  a  pro- 
jection of  the  upper  end  of  the  lower  fragment  forwards, 
and  that  this  deviation  is  due  to  the  nature  and  direction 


222  Surgical  Applied  Anatomy.     [Chap.  xi. 

of  the  violence,  and  not  to  muscular  action.  In  some 
cases  there  is  no  displacement,  the  broken  ends  being 
retained  in  situ,  probably,  by  the  biceps  tendon  and  the 
long  head  of  the  triceps.  In  at  least  one  instance  (Jar- 
javay)  the  lower  fragment  was  so  drawn  upwards  and 
outwards,  apparently  by  the  deltoid,  as  to  nearly  pierce 
the  skin  of  the  shoulder.  Hamilton  comes  to  the  general 
conclusion  "  that  complete  or  sensible  displacement  is 
less  common  at  this  fracture  than  in  most  other  frac- 
tures," and  in  this  conclusion  many  surgeons  agree. 

Amputation  at  the  shoulder  joint.— "Flap 
method "  •  "  deltoid  flap."  In  the  outer  flap  are  only 
the  deltoid  and  a  few  small  vessels  derived  from  the 
acromio-thoracic  and  the  two  circumflex  arteries.  The 
cephalic  vein  and  descending  branch  of  the  acromio- 
thoracic  artery  are  in  the  inner  flap.  The  anterior  and 
posterior  borders  of  the  inner  flap  show  portions  of  the 
deltoid  muscle.  Along  its  lower  border  from  before 
backwards  are  sections  of  the  pectoralis  major,  the  short 
head  of  the  biceps  and  coraco-brachialis,  the  axillary 
vessels  and  nerves,  the  latissimus  dorsi  and  teres  major, 
the  triceps,  and  the  posterior  portion  of  the  deltoid. 
The  trunks  of  the  posterior  circumflex  artery  and  nerve 
are  found  divided  on  the  posterior  part  of  the  surface 
of  the  flap,  between  the  sections  of  the  triceps  and  del- 
toid, and  not  far  from  the  angle  between  the  two  flaps. 

Oval  method  (Spence).  The  parts  cut  and  the  order 
of  their  division  are  practically  the  same  as  obtain  in 
the  anterior  and  inferior  borders  of  the  two  flaps  made 
in  the  previous  method.  The  anterior  incision,  being  a 
little  more  vertical  than  is  the  gap  between  the  two  flaps, 
divides  more  of  the  pectoralis  major  and  cuts  the  cephalic 
vein  higher  up.  The  posterior  circumflex  vessels  and 
nerve  are  separated  from  the  bone  by  the  finger  and  are 
retained,  one  advantage  of  the  procedure  being  that 
only  a  few  of  the  terminal  branches  of  that  artery  are 
divided. 


CHAPTER     XI  J. 

THE    AKM. 

The  arm,  upper  arm,  or  brachial  region  is  considered 
to  extend  from  the  axilla  above  to  the  region  of  the  elbow 
below. 

Surface  anatomy.— In  women,  and  in  those  who 
are  fat,  the  outline  of  the  arm  is  rounded  and  fairly 
regular.  It  is  less  regular  in  the  muscular,  in  whom 
it  may  be  represented  by  a  cylinder,  somewhat  flattened 
on  either  side  and  unduly  prominent  in  front  (biceps 
muscle).  The  outline  of  the  biceps  muscle  is  distinct, 
and  on  either  side  of  it  is  a  groove.  The  inner  of  the 
two  grooves  is  by  far  the  more  conspicuous.  It  runs  from 
the  bend  of  the  elbow  to  the  axilla,  and  indicates  gener- 
ally the  position  of  the  basilic  vein  and  brachial  artery. 
The  outer  groove  is  shallow,  and  ends  above  at  the  in- 
sertion of  the  deltoid  muscle.  So  far  as  it  goes  it  marks 
the  position  of  the  cephalic  vein. 

The  insertion  of  the  deltoid  can  be  well  made  out, 
and  is  an  important  landmark.  It  indicates  very  pre- 
cisely the  middle  of  the  shaft  of  the  humerus,  is  on 
the  same  level  with  the  insertion  of  the  coraco-brachialis 
muscle,  andmarkstheupper  limit  of  the  brachialis  anticus. 
It  corresponds  also  to  the  spot  where  the  cylindrical 
part  of  the  humeral  shaft  joins  the  prismatic  portion, 
to  the  point  of  entrance  of  the  nutrient  artery,  and  to 
the  level  at  which  the  musculo-spiral  nerve  and  superior 
profunda  artery  cross  the  back  of  the  bone. 

When  the  arm  is  extended  and  supinated,  the  brachial 
artery  corresponds  to  a  line  drawn  along  the  inner 
border  of  the  biceps,  from  the  outlet  of  the  axilla  (at 
the  junction  of  its  middle  and  anterior  thirds)  to  the 
middle  of  the  bend  of  the  elbow.  The  artery  is  super- 
ficial, and  can  be  felt  in  its  entire  extent.  In  its  upper 
two-thirds,  it  lies  on  the  inner  aspect  of  the  shaft  of  tie 
humerus,  and  can  be  compressed  against  the  bone 
by  pressure  in  a  direction  outwards  and  slightly  Lack 


224  Surgical  Applied  Anatomy,     [chap  xll. 

wards.  In  its  lower  third  the  humerus  lies  behind  it, 
and  compression,  to  be  effectual,  should  be  directed 
backwards. 

The  inferior  profunda  would  be  represented  by  a 
line  drawn  from  the  inner  side  of  the  humeral  shaft 
at  its  middle  to  the  back  part  of  the  internal  condyle. 
The  nutrient  artery  enters  the  bone  at  its  inner  aspect 
opposite  the  deltoid  insertion,  and  the  anastomotic 
vessel  comes  off  about  2  inches  above  the  bend  of  the 
elbow. 

The  ulnar  nerve  follows  first  the  brachial  artery, 
and  then  a  line  drawn  from  the  inner  side  of  that  vessel, 
about  the  level  of  the  insertion  of  the  coraco-brachialis 
to  the  gap  between  the  inner  condyle  and  the  olecranon. 
The  main  part  of  the  internal  cutaneous  nerve  is  be- 
neath the  inner  bicipital  groove,  while  the  superficial 
portion  of  the  musculo-cutaneous  corresponds  to  the 
lower  termination  of  the  outer  groove. 

The  arm. — The  skin  of  the  arm  is  thin  and  smooth, 
especially  in  front  and  at  the  sides.  It  is  very  mobile, 
being  but  loosely  attached  to  the  deeper  parts  by  a  lax 
subcutaneous  fascia.  In  circular  amputations'  of  the 
arm  this  looseness  of  the  integument  allows  it  to  be 
sufficiently  drawn  up  by  traction  with  the  hand  only. 
It  is  from  the  integument  covering  the  anterior  surface 
of  the  biceps  that  the  flap  is  fashioned  in  Tagliacozzi's 
operation  for  the  restoration  of  the  nose.  The  fineness 
of  the  skin  of  this  part,  and  its  freedom  from  hairs, 
render  it  very  suitable  for  this  procedure.  The  scanty 
attachments  of  the  skin  of  the  arm  allow  it  to  be  readily 
torn  or  stripped  away  in  lacerated  and  contused  wounds. 
Sometimes  in  these  lesions  large  flaps  of  integument 
are  violently  dissected  up.  The  looseness  of  the  sub- 
cutaneous tissues  favours  greatly  the  spread  of  inflam- 
matory processes,  while  its  comparative  thinness  allows 
of  the  early  manifestation  of  ecchymoses. 

The  limb  is  completely  invested  with  a  deep  fascia, 
the  brachial  aponeurosis,  as  by  a  sleeve.  The  fascia 
is  held  down  at  the  sides  by  the  two  intermuscular 
septa  which  are  attached  along  the  outer  and  inner 


chap,  xii.j  The  Arm. 


22 


margins  of  the  humerus,  running  from  the  deltoid 
insertion  to  the  outer  condyle  on  the  one  side,  and  from 
the  coraco-brachialis  insertion  to  the  inner  condyle 
on  the  other.  By  means  of  this  aponeurosis  and  its 
septa  the  arm  is  divided  into  two  compartments,  that 
can  be  well  seen  in  transverse  sections  of  the  limb. 
These  compartments  serve  to  confine  inflammatory 
and  hemorrhagic  effusions.  The  anterior  of  the  two 
spaces  has  the  less  substantial  boundaries,  owing  to 
the  thinness  of  the'  brachial  fascia  as  it  covers  the  biceps. 
Effusions  can  readily  pass  from  one  compartment  to 
the  other  by  following  the  course  of  those  structures 
that,  by  piercing  the  intermuscular  septa,  are  common 
to  both  spaces.  These  are  the  musculo-spiral  and 
ulnar  nerves,  the  superior  and  inferior  profunda,  and 
anastomotic  arteries.  The  principal  structures  that 
pierce  the  brachial  aponeurosis  itself  are  the  basilic 
vein,  a  little  below  the  middle  of  the  arm,  the  internal 
cutaneous  nerve,  about  the  middle,  and  the  external 
cutaneous  nerve,  just  above  the  elbow.  The  two  first 
named  are  in  the  inner  bicipital  groove,  and  the  last 
named  in  the  outer. 

The  skin  over  the  point  of  insertion  of  the  deltoid 
was  commonly  selected  as  a  suitable  place  for  an  issue 
at  a  time  when  that  remedy  was  popular.  The  reasons 
for  such  selection  were  the  absence  of  blood-vessels  of 
any  size  in  the  parts  beneath,  and  the  freedom  of  the 
spot  from  muscular  movement.  The  brachialis  anticus 
is  closely  adherent  to  the  bone,  while  the  biceps  is  free. 
It  follows,  therefore,  that  in  section  of  these  muscles, 
as  in  amputation,  the  latter  muscle  retracts  more  con- 
siderably than  does  the  former.  It  is  well,  therefore, 
in  performing  a  circular  amputation,  to  divide  the 
biceps  muscle  first,  and  then  after  it  has  retracted  to 
cut  the  brachialis  anticus. 

The  brachial  artery. — The  line  of  this  vessel 
has  already  been  given.  It  is  well  to  note  that  in  the 
very  muscular  the  artery  may  be  overlapped  to  a  con- 
siderable extent  by  the  biceps  muscle.  Compression 
,of  the   brachial,  unless   performed  carefully  with   tin- 


226  Surgical  Applied  Anatomy.    [Chap. xii. 

fingers,  can  hardly  avoid  at  the  same  time  compression 
of  the  median  nerve.  Thus,  no  doubt,  arises  the  severe 
pain  that  is  often  complained  of  when  tourniquets,  or 
circular  indiarubber  bands,  are  applied  to  the  limb. 
It  must  also  be  remembered  that  the  internal  cutaneous 
nerve  lies  in  front  of  the  vessel,  or  close  to  its  inner 
side,  until  it  pierces  the  fascia ;  that  the  ulnar  nerve 
lies  along  the  inner  side  of  the  artery  as  far  as  the  coraco- 
brachialis  insertion ;  and  that  behind  the  commencement 
of  the  vessel  is  the  musculo-spiral  nerve.  The  venae 
comites  are  placed  one  on  either  side  of  the  artery,  and 
communicate  frequently  with  one  another  by  short 
transverse  branches  which  directly  cross  the  vessel, 
and  which  may  give  trouble  in  operations  upon  the 
artery.  If  in  ligaturing  the  artery  at  its  middle  third 
the  arm  rests  upon  any  support,  the  triceps  may  be 
pushed  up  and  mistaken  for  the  biceps.  If  the  incisions 
be  too  much  to  the  inner  side  the  basilic  vein  may  be 
cut,  or  the  ulnar  nerve  exposed  and  mistaken  for  the 
median.  Tillaux  states  that  in  the  operation  a  large 
inferior  profunda  artery  has  been  taken  for  the  brachial. 
Inasmuch  as  the  median  nerve  often  derives  distinct 
pulsation  from  the  subjacent  vessel,  it  happens  that 
in  the  living  subject  it  has  been  confused  with  the  main 
artery  itself. 

Abnormalities  in  the  arrangement  of  the  brachial 
artery  are  so  frequent  (they  occur  in  12  to  15  per  cent, 
of  arms)  as  to  be  of  surgical  importance.  It  is  not 
unusual  to  find  a  collateral  branch  (vas  aberrans)  arising 
from  the  upper  part  of  the  brachial  or  lower  part  of  the 
axillary,  passing  down  the  arm,  superficial  to  the  median 
nerve,  and  ending  in  the  radial  or  sometimes  the  ulnar 
artery.  The  vas  aberrans  may  replace  the  brachial, 
in  which  case  the  artery  will  be  found  superficial  instead 
of  deep  to  the  main  vessel,  and  the  profunda  vessels 
arise  from  the  remnant  of  the  real  brachial  artery. 
This  superficial  brachial  vessel  may  pass  under  the 
supra-condyloid  process,  a  hooked  projection  of  bone 
which  occasionally  springs  from  the  inner  aspect  of 
the  humerus,  2  inches  above  the  epicondyle. 


chap.  xii. j  The  Arm.  227 

The  musculo-spiral  nerve,  from  its  close 
contact  with  the  bone,  which  it  crosses  at  the  level 
of  the  deltoid  insertion,  is  frequently  injured  and  torn. 
Thus  it  has  been  damaged  in  severe  contusions,  in  kicks, 
in  stabs,  in  bites  from  horses,  and  very  frequently  in 
fractures  of  the  humeral  shaft ;  or  the  nerve  may  be 
sound  at  the  time  of  fracture,  and  become  subsequently 
so  involved  in  the  callus  formed  as  to  lead  to  paralysis 
of  the  parts  it  supplies.  In  a  case  reported  by  Tillaux, 
where  paralysis  followed  some  time  after  a  fracture, 
the  nerve  was  found  embedded  in  callus,  and  on  cutting 
some  of  the  redundant  mass  away  a  good  recovery 
followed.  In  several  instances  the  nerve  has  been 
paralysed  by  the  pressure  of  the  head  when  a  man 
has  slept  with  his  head  resting  on  the  arm  in  the  position 
of  full  supination  and  abduction.  It  is  said  to  be  often 
paralysed  in  Russian  coachmen  who  fall  asleep  with 
the  reins  wound  round  the  upper  arm.  It  has  also 
been  frequently  damaged  by  the  pressure  of  badly 
constructed  crutches,  especially  those  that  afford  no 
proper  support  for  the  hand.  Indeed,  it  is  the  nerve 
most  often  affected  in  "  crutch  paralysis,"  the  ulnar 
being  the  trunk  that  suffers  next  in  frequency. 

Fracture  of  the  shaft  ot  the  humerus  is 
usually  due  to  direct  violence.  The  shaft  may,  how- 
ever, be  broken  by  indirect  violence,  and  of  all  bones 
the  humerus  is  said  to  be  the  one  most  frequently  frac- 
tured by  muscular  action.  As  examples  of  the  latter 
may  be  noted  the  throwing  of  a  ball,  the  clutching 
at  a  support  to  prevent  a  fall,  and  the  so-called  trial 
of  strength  known  as  "  wrist  turning."  When  the 
bone  is  broken  above  the  deltoid  insertion  the  lower 
fragment  may  be  drawn  upwards  by  the  biceps,  triceps, 
and  deltoid,  and  outwards  by  the  last-named  muscle  ; 
while  the  upper  fragment  is  drawn  inwards  by  the 
muscles  attached  to  the  bicipital  groove.  When  the 
fracture  is  below  the  deltoid  insertion,  the  lower  end 
of  the  upper  fragment  may  be  carried  outwards  by 
that  muscle,  while  the  lower  fragment  is  drawn  upwards 
to    its    inner    side    by    the    biceps    and    triceps.      The 


228  Surgical  Applied  Anatomy.    [Chap.  xn. 

deformity,  however,  as  a  rule  depends  much  more 
upon  the  nature  and  direction  of  the  force  that  breaks 
the  bone  than  upon  any  muscular  action.  The  dis- 
placements just  noted  may  be  met  with,  but  usually 
they  are  quite  independent  of  the  relation  of  the  deltoid 
insertion  to  the  seat  of  fracture,  and  cannot  be  tabulated. 
The  weight  of  the  arm  seldom  allows  of  more  than 
three-quarters  of  an  inch  of  shortening. 

The  humerus  is  more  frequently  the  seat  of  non-union 
after  fracture  than  is  any  other  bone.  This  result  is 
quite  independent  of  the  position  of  the  fracture  in 
relation  to  the  nutrient  artery.  Hamilton's  explanation 
is  briefly  this  :  the  fracture  is  usually  so  adjusted  that 
the  elbow  is  flexed  ;  this  joint  soon  becomes  fixed  by 
muscular  rigidity,  and  when  any  movement  is  made  as 
if  to  flex  or  extend  the  fore-arm  on  the  arm,  that  move- 
ment no  longer  occurs  at  the  elbow,  joint,  but  at  the 
seat  of  fracture.  Thus,  if  the  arm  be  in  a  sling, 
and  the  patient  allows  the  hand  to  drop  by  relaxing 
that  sling,  it  is  maintained  that  the  bulk  of  that  move- 
ment will  take  place  about  the  fracture  line.  There 
are  many  objections  to  this  theory.  If  true,  the  tendency 
to  movement  about  the  fragments  would  be  the  greater 
the  farther  the  fracture  is  from  the  elbow  joint,  but 
non-union  is  more  common  at  the  middle  than  at  the 
upper  third  of  the  shaft.  Probably  many  causes  con- 
spire to  bring  about  non-union  of  fractures  of  this  bone, 
among  which  may  be  mentioned  the  imperfect  fixing 
of  the  joint  above  the  fracture,  and  the  inadequate 
support  afforded  to  the  elbow,  whereby  the  weight 
of  the  arm  and  of  the  splints  tends  to  drag  the  lower 
fragment  out  of  the  proper  line  it  should  form  with 
the  upper  fragment.  The  most  effective  cause  would 
appear  to  be  due  to  the  entanglement  of  muscular  tissue 
between  the  broken  ends,  for  it  must  be  remembered 
that  the  shaft  of  the  bone  is  closely  surrounded  by 
muscular  fibres  that  are  directly  adherent  to  its  surfaces. 
Thus,  in  an  oblique  fracture  the  end  of  one  fragment 
may  be  driven  into  the  brachialis  anticus,  while  the 
other  end  projects  into  the  substance  of   the   triceps, 


Chap.  XII. j 


The  Arm. 


229 


and  immediate  contact  of  the  bones  may  be  consequently 
prevented. 

Amputation  through  the  middle  of  the 
arm. — Circular  method  :  The  parts  divided  in  this 
amputation  are  fully  shown  in  Fig.  29.  Flap  method  : 
Two  flaps  of  about  equal  size  and  shape  may  be  cut 
antero-posteriorly,  the  arm  being  well  rotated  outwards. 
In  the  anterior  flap 
would  be  the  biceps 
and  the  greater  part 
of  the  brachialis  anti- 
cus,  with  the  musculo- 
cutaneous nerve  be- 
tween them,  and  a 
small  piece  of  the 
triceps  from  the  inner 
side  of  the  limb.  The 
brachial  vessels,  the 
median  and  ulnar 
nerves,  and  possibly 
the  inferior  profunda 
artery,  are  also  found 
in  this  flap,  about  the 
inner     angle    of    the 

stump.      The    basilic  ^•«^fS2K?5fteSSS,ltfli,ie 
vein     and      internal 
cutaneous    nerve    lie 
about  the  inner  border 
of  the   anterior   flap, 

and  the  cephalic  vein  about  its  outer  border.  In 
the  posterior  flap  would  be  the  triceps,  any  small  part 
of  the  outer  portion  of  the  brachialis  not  divided  in  the 
anterior  flap,  the  superior  profunda  artery,  and  the 
musculo-spiral  nerve.  If  the  amputation  be  lower 
down  in  the  arm,  the  ulnar  nerve  and  inferior  profunda 
artery  may  be  found  in  the  posterior  instead  of  the 
anterior  flap.  Since  the  nutrient  artery  enters  the 
bone  about  the  insertion  of  the  coraco-brachialis  and 
runs  towards  the  elbow,  it  would  be  divided  in  these 
amputations,  and  might  give  trouble. 


middle  of  the  Arm  (Braune). 

Biceps;  b,  coraco-brachialis :  c,  brachialis 
amicus  ;  d,  triceps  ;  1,  brachial  artery  ;  2,  me- 
dian nerve;  3, ulnar  nerve;  4, musculo  spiral 
nerve. 


230 

CHAPTER    XIII. 

THE  REGION  OF  THE  ELBOW. 

Surface  anatomy. — On  the  anterior  aspect  of  the 
elbow  are  seen  three  muscular  elevations.     One,  above 
and  in  the  centre,  corresponds  to  the  biceps  and  its 
tendon  ;    while,  of  the  two  below  and  at  the  sides,  the 
outer   corresponds   to   the   supinator   longus   and   the 
common  extensor  mass,  and  the  inner  to  the  pronator 
radii  teres  and  the  common  set  of  flexor  muscles.     The 
arrangement  of  these  elevations  is  such  that  two  grooves 
are  formed,  one  on  either  side  of  the  biceps  and  its  tendon. 
The  grooves  diverge  above,  and  join  the  outer  and  inner 
bicipital  grooves,  while  below  they  meet  over  the  most 
prominent  part  of  the  tendon,  and  thus  form  together 
a  V-shaped  depression.     The  distinctness  of  these  details 
depends  upon  the  thinness  and  muscular  development 
of  the  individual.     In  the  inner  of  the  two  grooves  are 
to  be  found  the  median  nerve  and  the  brachial  artery 
and  its  veins  ;  while  deeply  placed  below  the  outer  groove 
are  the  terminations  of  the  musculo-spiral  nerve  and 
superior   profunda   artery,    with   the   small   radial   re- 
current vessel.     The  biceps  tendon  can  generally  be  very 
distinctly  felt.     Its  outer  border  is  more  evident  than 
is  its  inner  edge,  owing  to  the  connection  of  the  bicipital 
fascia  with  the  latter  side  of  the  tendon.     Extending 
transversely  across  the  front  of  this  region  is  a  crease 
in  the  integument,  the  "  fold  of  the  elbow."      This  fold 
is  not  a  straight  line,  but  is  convex  below.     It  is  placed 
some  little  way  above  the  line  of  the  articulation,  and  its 
lateral  terminations  correspond  to  the  tips  of  the  two 
condylar  eminences.     In  backward  dislocations  of  the 
elbow  the  lower  end  of  the  humerus  appears  about 
1    inch    below  this  fold,  whereas  in  a  fracture  of  the 
humerus  just  above  the  condyles  the  fold  is  either  opposite 
to  the  prominence  formed  by  the  lower  end  of  the  upper 
fragment,   or   is   below   it.     This   crease   is   obliterated 
on  extension. 


chap,  xni.]    The  Region  of  the  Elbow.  231 

At  the  apex  of  the  V-shaped  depression,  about  the 
spot  where  the  biceps  tendon  ceases  to  be  distinctly 
felt,  and  at  the  outer  side  of  that  tendon,  the  median 
vein  divides  into  the  median  basilic  and  the  median 
cephalic.  At  the  same  spot  also  the  deep  median  vein 
joins  the  superficial  vessels.  The  median  basilic  vein 
can  be  seen  to  cross  the  biceps  tendon,  to  follow  more 
or  less  closely  the  groove  along  the  inner  border  of  the 
muscle,  and  to  join,  a  little  above  the  internal  condyle, 
with  the  posterior  ulnar  vein  to  form  the  basilic  trunk. 
The  median  cephalic,  following  the  groove  at  the  outer 
margin  of  the  biceps,  joins,  about  the  level  of  the  external 
condyle,  with  the  radial  vein  to  form  the  cephalic  vein. 
The  brachial  artery  bifurcates  about  a  finger's  breadth 
below  the  centre  of  the  bend  of  the  elbow.  "  The  coro- 
noid  process  of  the  ulna  can  be  indistinctly  felt,  if  firm 
pressure  is  made  in  the  triangular  space  in  front  of  the 
joint "  (Chiene).  The  points  of  the  two  condyles  can 
always  be  felt.  The  internal  condyle  is  the  more  prom- 
inent and  the  less  rounded  of  the  two.  The  humero- 
radial articulation  forms  a  horizontal  line,  but  the 
humero-ulnar  joint  is  oblique,  the  joint  surfaces  sloping 
downwards  and  inwards.  Thus  it  happens  that  while 
the  external  condyle  is  only  f  of  an  inch  (18  mm.)  above 
the  articular  line,  the  point  of  the  internal  condyle  is 
more  than  1  inch  (28  mm.)  above  that  part  (Paulet). 
From  the  obliquity  of  the  joint  surfaces  between  the 
ulna  and  humerus,  it  follows  that  the  fore-arm,  when 
in  extension,  is  not  in  a  straight  line  with  the  upper 
arm,  but  forms  with  it  an  angle  that  opens  outwards. 
Thus,  when  traction  is  made  upon  the  entire  upper 
limb  from  the  wrist,  some  of  the  extending  force  is 
necessarily  lost,  and  such  traction,  therefore,  should 
be  applied  from  the  elbow,  as  is  the  usual  practice  rn 
reducing  a  dislocation  of  the  shoulder  by  manipulation. 
A  line  drawn  through  the  two  condyles  will  be  at  right 
angles  with  the  axis  of  the  upper  arm,  while  it  will  form 
an  angle  with  the  axis  of  the  fore-arm.  Thus  if  we  look 
at  the  upper  arm,  the  two  condyles  are  on  the  same 
level,   whereas,   when   viewed   from  the  fore-arm,   the 


232  Surgical  Applied  Anatomy.  [Chap.  xiii. 

inner  condyle  lies  at  a  higher  level  than  does  the  external 
process. 

The  joint  line  of  the  elbow  is  equivalent  only  to 
about  two-thirds  of  the  width  of  the  entire  line  between 
the  points  of  the  two  condyles  (Fig.  31,  p.  243).  The 
prominence  of  the  condyles  forms  a  capital  point  oVappui 
for  traction  by  encircling  bands  applied  to  the  limb 
above  the  elbow  joint.  At  the  back  of  the  elbow  the 
prominence  of  the  olecranon  is  always  to  be  distinctly 
felt.  It  lies  nearer  the  internal  than  the  external  con- 
dyle. In  extreme  extension  the  summit  of  the  olecranon 
is  a  little  above  the  line  joining  the  two  condyles.  When 
the  fore-arm  is  at  right  angles  with  the  arm,  the  tip  of 
the  process  is  below  the  line  of  the  condyles,  and  in 
extreme  flexion  it  lies  wholly  in  front  of  that  line.  Be- 
tween the  olecranon  and  the  inner  condyle  is  a  depression 
that  lodges  the  ulnar  nerve  and  the  posterior  ulnar 
recurrent  artery. 

To  the  outer  side  of  the  olecranon,  and  just  below 
the  external  condyle,  there  is  a  depression  in  the  skin 
which  is  very  obvious  when  the  limb  is  extended.  This 
pit  is  to  be  seen  even  in  those  who  are  fat,  and  also 
in  young  children.  In  it  the  head  of  the  radius  can  be 
felt,  and  can  be  well  distinguished  when  the  bone  is 
rotated  in  pronation  and  supination.  The  pit  corre- 
sponds to  the  hollow  between  the  outer  border  of  the 
anconeus  and  the  muscular  eminence  formed  by.  the 
two  radial  extensors  of  the  carpus  and  the  supinator 
longus.  The  highest  point  of  the  bone  that  can  be 
felt  moving  on  rotation  will  correspond  to  the  radius 
immediately  below  the  line  of  the  elbow  joint,  and  is  a 
valuable  guide  to  that  articulation.  The  upper  limit  of 
the  elbow  joint  reaches  a  line  drawn  between  the  point 
of  the  two  condyles.  The  tubercle  of  the  radius  can  be 
felt  just  below  the  head  of  the  bone  when  the  limb  is  in 
the  position  of  extreme  pronation. 

The  region  of  the  elbow. — The  skin  in  front 
of  the  elbow  is  thin  and  fine,  and  is  readily  excoriated 
by  tight  bandaging  and  by  improperly  applied  splints. 
The  thinness  of  the  skin  allows  the  subjacent  veins  to 


chSp.  xiii.]    The  Region  of  the  Elbow. 


m 


be    easily    seen    through    the    integuments,    but    the 

distinctness    with    which    these    veins    appear    depends 

mainly   upon   the   amount   of   subcutaneous   fat.      In 

the  very  stout  they  may  be  quite  invisible,  and  it  may 

be  difficult  or  impossible  to  render 

them  evident  by  the  usual  means 

adopted  in  venesection.     Tillaux 

points   out  that  if  such  people 

are  bled  a  pellet  of  fat  will  often 

project    into    the    wound    and 

prevent  the  flow  of  blood. 

The  arrangement  of  the 
superficial  veins  in  front  of 
the  elbow,  so  as  to  form  an 
M-shaped  figure,  is  familiar,  but 
it  must  be  confessed  that  it  is 
by  no  means  constant  (Fig.  30). 
So  far  as  I  have  seen,  it  would 
appear  that  the  precise  M-like 
arrangement  figured  in  most 
books  is  only  present  in  about 
two-thirds,  and  perhaps  in  only 
one-half,  of  all  cases. 

The  median  vein  breaks  up 
into  the  median  cephalic  and 
median  basilic,  just  to  the  outer 
side  of  the  biceps  tendon,  and, 
therefore,  the  latter  vein  passes 
in  front  of  the  tendon,  of  the 
brachial  artery  and  its  veins, 
and  of  the  median  nerve.  From 
these  structures  it  is  separated 
by  the  bicipital  fascia.  The 
median  basilic   vein  may    cross 

the  brachial  artery  abruptly,  and  be  comparatively 
free  of  it,  except  at  the  point  of  crossing,  or  it 
may  run  for  some  distance  quite  in  front  of  the 
artery,  or,  crossing  it  early,  it  may  lie  parallel  with  the 
vessel,  although  at  a  different  level,  for  the  greater  part 
of  its  course.     As   regards   size,   the   median   basilic   is 


Fig.  30.—  The  Left  Elbow 
from  in  front. 

a,  Basilic  vein;  b,  cephalic 
vein;  c.  on  the  ulna  ooints 
to    median    basilic    vein; 

d,  on  the  radius  points  to 
median      cephalic     vein; 

e,  radial  vein;  /,  median 
vein;  g,  posterior  ulnar 
vein. 


234  Surgical  Applied  Anatomy,  tchap.  xm. 

usually  the  largest  of  these  veins,  the  median  cephalic 
coming  next,  and  the  median  itself  third,  while  the  ulnar 
and  radial  veins  are  the  smallest  of  the  series.  These 
veins  are  liable  to  many  abnormalities,  some  of  the  most 
conspicuous  being  in  cases  where  the  main  arteries  of 
the  part  also  are  abnormal.  The  deviation  is  more  usual 
in  the  veins  on  the  radial  than  in  those  on  the  ulnar 
side  of  the  limb.  Thus  it  is  common  for  the  radial 
or  the  median  cephalic  veins,  or  both,  to  be  either  very 
defective  or  entirely  absent.  In  spite  of  the  relation 
the  median  basilic  vein  bears  to  the  brachial  artery, 
it  is  nevertheless  the  vein  usually  selected  in  venesection 
and  transfusion.  The  reasons  for  its  selection  are  these  : 
it  is  usually  the  largest  and  most  prominent  of  the  veins, 
and  the  one  the  nearest  to  the  surface  ;  it  is  also  the 
least  movable  vein,  and  the  one  the  least  subject  to 
variation.  The  bicipital  fascia  forms  an  excellent  pro- 
tection to  the  brachial  artery  during  phlebotomy.  The 
density  of  that  membrane  varies,  and  depends  mainly 
upon  the  degree  of  muscular  development.  In  thin 
subjects  the  median  basilic  vein  may  receive  pulsations 
from  the  subjacent  artery.  According  to  one  observer, 
the  walls  of  this  vein  are  often  as  thick  as  those  of  the 
popliteal  vein.  The  ulnar,  radial,  and  median  veins 
seldom  yield  enough  blood  on  venesection,  since  they 
are  below  the  point  of  junction  of  the  deep  median  vein, 
and  thus  do  not  receive  blood  from  the  deep  veins  of  the 
limb.  The  brachial  artery  has,  as  may  be  supposed, 
been  frequently  injured  in  bleeding  ;  and  at  the  period 
when  venesection  was  very  commonly  practised,  arterio- 
venous aneurisms  at  the  bend  of  the  elbow  were  not 
infrequent.  Since  the  principal  superficial  lymphatic 
vessels  run  with  these  veins,  and  since  some  of  them 
can  scarcely  escape  injury  in  phlebotomy,  it  follows 
that  an  acute  lymphangitis  is  not  uncommon  after  the 
operation,  especially  when,  the  point  of  the  lancet  being 
unclean,  septic  matter  is  introduced  into  the  wound. 

The  internal  cutaneous  nerve,  which  usually  runs  in 
front  of  the  median  basilic  vein,  may  be  wounded  in 
bleeding" from  that  vessel.     The  injury  to  the   nerve, 


chap,  xin.]    The  Region  of  the  Elbow.  235 

according  to  Tillaux,  may  lead  to  "  traumatic  neuralgia 
of  extreme  intensity,  and  very  chronic."  A  "  bent  arm  " 
may  follow  after  venesection,  and  Mr.  Hilton  believes 
this  to  be  often  due  to  injury  to  the  filaments  of  the 
musculo-cuta neons  nerve,  espe  -ially  to  the  inclusion 
of  those  filaments  in  a  scar  left  by  the  operation.  The 
cutaneous  branches  of  this  nerve  lie  over  the  median 
cephalic  vein.  These  peripheral  fibres  being  irritated, 
the  muscles  supplied  from  the  same  segment  of  the  cord 
(biceps  and  brachialis  anticus)  are  caused  to  contract 
by  reflex  action.  Hence  the  bent  arm.  In  one  case 
he  cured  a  bent  arm  following  bleeding  by  resecting 
the  old  scar,  which  on  removal  was  found  to  have  in- 
cluded within  its  substance  some  nerve  filaments. 

There  is  a  lymphatic  gland  situated  over  the 
internal  intermuscular  septum  of  the  arm,  and  just 
above  the  internal  condyle.  It  receives  some  of  the 
surface  lymphatics  from  the  inner  side  of  the  fore-arm, 
and  two  or  three  inner  fingers.  In  position,  it  is  the 
lowest  gland  in  the  upper  limb. 

The  brachial  artery. — In  forcible  flexion  of  the 
limb  the  artery  is  compressed  between  the  muscular 
masses  in  front  of  the  joint,  and  the  radial  pulse  is  much 
diminished  or  even  checked.  The  artery  may  divide 
in  the  lower  third  of  the  arm.  and  in  such  cases  the 
ulnar  artery  may  pass  over  the  bicipital  fascia.  Aneur- 
isms at  the  bend  of  the  elbow  have  been  treated  by  flexion 
of  the  limb,  that  position  bringing  more  or  less  direct 
pressure  to  bear  upon  the  sac.  In  full  extension  of  the 
joint  the  artery  becomes  flattened  out,  and  the  radial 
pulse  diminished.  In  the  over  extension  possible  with 
fractured  olecranon  the  pulse  may  be  stopped  at  the 
wrist.  Forcible  extension  of  an  elbow  that  has  become 
rigid  in  the  bent  position  has  caused  rupture  of  the 
brachial  artery. 

The  ulnar  nerve  is,  from  its  position  at  the 
elbow,  very  liable  to  be  injured.  It  passes  on  a  groove 
behind  the  internal  epicondyle.  The  nerve  may  pass 
in  front  of  the  internal  condyle,  and  an  instance  is 
reported   where  the   nerve  slipped  forward    over   that 


236  Surgical  Applied  Anatomy.  [Chap.  xin. 

eminence  whenever  the  elbow  was  bent(Quain).  In  cases 
where  an  abnormal  brachial  passes  beneath  a  supra- 
condyloid  process  the  median  nerve  goes  with  the  artery. 
In  exposing  the  ulnar  nerve  (for  nerve  stretching,  etc.) 
behind  the  elbow  the  nerve  may  be  found  quite  covered 
by  an  occasional  muscle,  the  epitrochleo-anconeus. 

The  elbow  joint. — The  strength  of  this  joint 
depends  not  so  much  upon  either  ligaments  or  muscles 
as  upon  the  coaptation  of  the  bony  surfaces.  The 
relations  of  the  olecranon  and  coronoid  process  to  the 
humerus  are  such  that  in  certain  positions  the  strength 
of  the  joint  is  very  considerable. 

The  elbow,  being  a  pure  hinge-joint,  permits  only  of 
flexion  and  extension.  These  movements  are  oblique, 
so  that  in  flexion  the  fore-arm  inclines  inwards,  carrying 
the  hand  towards  the  middle  third  of  the  clavicle.  If 
it  were  not  for  the  obliquity  of  the  joint  line  it  wo  aid 
be  possible  for  the  hand  to  be  placed  flat  upon  the 
shoulder  of  the  same  side,  but  this  movement  is  only 
possible  after  some  excisions  of  the  joint,  for  in  this 
operation  the  oblique  direction  of  the  articular  surfaces 
is  not  reproduced.  In  extreme  extension  the  ulna  is 
nearly  in  a  straight  line  with  the  humerus  as  regards 
their  lateral  planes,  while  in  extreme  flexion  the  two 
bones  form  an  angle  of  from  30°  to  40°. 

Bur  see. — Of  the  bursas  about  the  joint  the  large 
subcutaneous  bursa  over  the  olecranon  is  very  com- 
monly found  enlarged  and  inflamed  ;  and  when  inflamed 
may  lead  to  extensive  mischief  in  the  limb.  Its  enlarge- 
ment is  favoured  by  certain  employments  involving 
pressure  on  the  elbow ;  thus,  the  disease  known  as 
"  miner's  elbow  "  is  merely  an  enlargement  of  this  sac. 
There  is  a  bursa  between  the  biceps  tendon  at  its 
insertion  and  the  bone,  the  relations  of  which  to  the 
nerves  of  the  fore-arm  are  worth  noting.  A  case,  for 
instance,  is  reported  where  this  bursa  became  chronically 
enlarged,  and  by  pressing  upon  the  median  and  posterior 
interosseous  nerves  produced  loss  of  power  in  the  fore-arm 
(Agnew). 

Of  the  ligaments  of  the  elbow-joint,  the  anterior 


Chap,  xin.]    The  Region  of  the  Elbow.  237 

and  posterior  are  comparatively  thin,  and  the  latter 
especially  soon  yields  to  the  pressure  of  fluid  within 
the  joint  in  disease  of  the  articulation.  The  internal 
lateral  is  the  strongest  and  most  extensive  of  the  liga- 
ments of  the  part.  From  its  rigidity,  its  extended 
attachment,  and  the  fact  that  it  serves  to  limit  not 
only  flexion  and  extension,  but  also  any  attempt  to 
wrench  the  fore-arm  laterally  from  the  arm,  it  happens 
that  it  is  the  ligament  that  suffers  the  most  often  in 
"  sprains  "  of  the  elbow.  As  this  ligament  is  attached 
to  the  whole  length  of  the  inner  border  of  the  olecranon, 
it  may  assist  in  preventing  separation  of  the  fragments 
when  that  process  has  been  fractured. 

Joint  disease. — In  disease  of  this  joint  the 
effusion  first,  and  most  distinctly,  shows  itself  by  a 
swelling  around  the  margins  of  the  olecranon.  This 
is  explained  by  the  facts  that  the  synovial  cavity  is 
here  nearest  to  the  surface,  and  that  the  posterior  liga- 
ment is  lax  and  thin.  Some  swelling  is  also  soon  noticed 
about  the  line  of  the  radio-humeral  joint,  and  fluctuation 
in  this  situation  serves  to  distinguish  joint  effusion 
from  simple  enlargement  of  the  bursa  beneath  the 
triceps  tendon.  Deep-seating  swelling  may  be  noted 
about  the  front  of  the  joint  beneath  the  brachialis 
anticus,  owing  to  the  thinness  of  the  anterior  ligament ; 
and  lastly,  about  the  external  condyle.  The  density 
of  the  internal  ligament  prevents  a  bulging  of  the 
synovial  membrane  on  the  inner  side.  When  the 
joint  suppurates  the  pus  will  most  easily  reach  the 
surface  by  travelling  upwards  and  backwards  between 
the  humerus  and  the.  triceps,  and  the  abscess  points, 
therefore,  very  commonly  at  one  or  other  border  of  that 
muscle.  The  pus  may  escape  beneath  the  brachialis 
anticus  in  front,  and  discharge  itself  near  the  insertion 
of  the  muscle.  When  the  bone  is  diseased  the  sinuses 
form  usually  directly  over  the  part  attacked.  The 
diseased  elbow  tends  to  assume  the  posture  of  semi- 
flexion, and  it  is  interesting  to  observe  that  that  is  the 
position  assumed  by  the  joint  when  forcible  injections 
are  made  into  its  cavity  (Braune).     The  joint,  in  fact, 


.:> 


8  Surgical  Applied  Anatomy.  [Chap.  xin. 


holds  the  greatest  amount  of  fluid  when  it  is  semi-flexed. 
As  regards  muscular  rigidity  of  the  elbow,  due  to  reflex 
irritation  from  disease,  it  is  well  to  note  that  all  the 
nerves  of  the  articulation  supply  muscles  acting  upon 
the  joint,  notably  the  musculo-spiral  and  musculo- 
cutaneous. The  relation  of  the  ulnar  nerve  to  the 
joint  serves  to  explain  cases  where  severe  pain  has  been 
felt  along  the  fore-arm  and  in  the  fingers,  in  parts  cor- 
responding to  the  distribution  of  that  nerve.  The 
upper  epiphysis  of  the  radius  and  the  greater  part  of 
the  lower  epiphysis  of  the  humerus  are  intrasynovial, 
i.e.  come  within  the  capsule  of  the  joint.  The  com- 
paratively small  upper  epiphysis  of  the  ulna  is  only 
partly  within  the  capsule  (Fig.  31,  p.  243). 

Dislocations  of  the  elbow. — These  are  many, 
and  may  be  thus  arranged.  (1)  Dislocations  of  both 
radius  and  ulna  either  backwards,  outwards,  inwards, 
or  forwards  (in  order  of  frequency).  (2)  Dislocations 
of  the  radius  alone  either  forwards,  backwards,  or 
outwards  (in  order  of  frequency).  (3)  Luxation  of 
the  ulna  alone  backwards. 

As  a  preliminary  it  may  be  convenient  to  note  some 
general  anatomical  considerations  in  connection  with 
these  various  displacements. 

(a)  Antero-posterior  luxations  are  much  more  common 
than  are  lateral  £w&afao?is.-Displacements  in  the  antero- 
posterior direction  are  more  common  because  the 
movements  of  the  joint  take  place  in  that  direction, 
and  the  width  of  the  articular  surface  of  the  humerus 
from  before  backwards  is  comparatively  small.  On 
the  other  hand,  there  is  normally  no  lateral  movement 
of  the  elbow,  and  the  width  of  the  articulation  from 
side  to  side  is  considerable.  The  antero-posterior  liga- 
ments are  feeble,  while  the  lateral  ligaments  are  strong, 
and  the  joint,  moreover,  receives  more  muscular  support 
at  its  sides  than  it  does  either  behind  or  in  front.  The 
mutual  support  afforded  by  the  bones  to  one  another 
is  weakened  in  the  antero-posterior  direction  during 
certain  movements.  Thus  in  full  flexion  the  olecranon 
has  but  a  feeble  hold  upon    the    humerus,   while  in 


chap,  xii i.]    The  Region  of  the  Elbow.  239 

extension  the  hold  of  the  coronoid  process  upon  that 
bone  is  even  less.  In  a  lateral  direction,  however, 
movement  has  but  a  very  slight  effect  upon  the  support 
the  bones  mutually  derive  from  one  another. 

(b)  Both  bones  of  the  fore-arm  are  more  often 
luxated  together  than  is  either  the  radius  alone  or  the 
ulna  alone.  This  depends  upon  the  powerful  liga- 
mentous connection  between  the  radius  and  ulna  on 
the  one  hand,  and  the  absence  of  such  connection 
between  the  humerus  and  the  radius  on  the  other. 
In  the  dead  subject  it  is  not  difficult  to  dislocate  the 
two  bones  of  the  fore-arm,  but  it  is  extremely  difficult 
to  separate  the  radius  from  the  ulna  without  great 
breaking  and  tearing  of  parts. 

(c)  The  commonest  dislocation  of  the  two  bones 
together  is  backwards,  the  rarest  is  forwards. — In  the 
former  instance  the  movement  is  resisted  by  the  small 
coronoid  process,  in  the  latter  by  the  large  and  curved 
olecranon.  For  like  reasons  the  luxation  outwards 
is  less  rare  than  is  the  displacement  inwards,  since  the 
articular  surface  of  the  humerus  inclines  downwards 
and  inwards  on  the  inner  side,  and  thus  affords  a  greater 
obstacle  in  that  quarter. 

(d)  If  a  single  bone  be  dislocated  it  will  usually  be 
the  radius. — This  follows  from  the  absence  of  reliable 
union  between  that  bone  and  the  humerus,  from  the 
greater  exposure  of  the  radius  ("  the  handle  of  the  hand  ") 
to  indirect  violence,  and  from  its  greater  mobility. 
The  luxation  is  usually  forwards,  due  to  the  fact  that 
the  forms  of  violence  that  tend  most  often  to  displace 
the  bone  tend  also  to  draw  it  forwards.  Paulet  asserts 
that  the  posterior  part  of  the  annular  ligament  is  "  much 
more  resistant "  than  is  the  anterior  part.  The  luxation 
of  the  ulna  alone  occurs  in  the  backward  direction, 
for  reasons  that  will  be  obvious. 

Dislocations  of  the  elbow  of  all  kinds  may  be  partial 
or  complete.  More  usually  they  are  complete  when 
in  the  antero-posterior  direction,  and  partial  when  the 
luxation  is  lateral. 

Some  more  detailed   notice  mav  now  be  taken  of 


240  Surgical  Applied  Anatomy.  [Cha.-..  xm. 

the  only  two  forms  of  dislocation  at  the  elbow  that 
are  at  all  common. 

(1)  Displacement  of  both  bones  back- 
wards.— This  may  be  effected  during  forced  exten- 
sion. Here  the  point  of  the  olecranon  pressed  against 
the  humerus  acts  as  the  fulcrum  of  a  lever  of  the  second 
kind,  and  tends  to  tear  the  ulna  from  the  lateral  bone. 
The  addition  of  violence  to  the  fore-arm  in  a  backward 
or  upward  direction  would  effect  the  actual  displacement. 
This  condition  may  be  illustrated  by  a  fall,  as  in  running, 
upon  the  fully  extended  hand.  The  lesion  may  also  be 
produced  by  certain  violent  wrenchings  of  the  limb. 
Malgaigne  maintained  that  the  particular  kind  of  wrench 
most  effectual  in  producing  luxation  was  a  twisting 
inwards  of  the  fore-arm  while  the  elbow  was  semi-flexed. 
In  this  way  the  internal  lateral  ligament  was  ruptured, 
and  the  coronoid  process  twisted  inwards  and  downwards 
under  the  humerus,  and  the  bones  thus  displaced  back. 
This  lesion  would  be  difficult  to  effect  while  the  joint 
was  fully  flexed.  In  the  complete  form  the  coronoid 
process  is  opposite  to  the  olecranon  fossa.  It  can  hardly 
occupy  that  hollow  (as  sometimes  described)^  since  the 
connection  of  the  ulna  to  the  radius,  and  the  projection 
of  the  latter  bone  behind  the  outer  condyle,  would 
prevent  it  from  actually  falling  into  the  fossa.  The 
anterior  and  the  two  lateral  ligaments  are  usually  more 
or  less  entirely  torn,  while  the  posterior  and  the  orbi- 
cular ligaments  escape.  The  biceps  is  drawn  over  the 
lower  end  of  the  humerus,  and  is  rendered  moderately 
tense.  The  brachialis  anticus  is  much  stretched  and 
often  torn.  The  anconeus  is  made  very  tense.  Both 
the  median  and  ulnar  nerves  may  be  severely  stretched. 

(2)  Dislocation  of  the  radius  forwards. — This 
may  be  due  to  direct  violence  to  the  bone  from  behind, 
or  to  extreme  pronation,  or  to  falls  upon  the  extended 
and  pronated  hand.  The  anterior,  external,  and  an- 
nular ligaments  are  torn.  There  would  seem  to  be  a 
lack  of  evidence  in  support  of  Hamilton's  statement 
that  "  sometimes  the  auterior  and  external  lateral 
are   alone  broken,  the  annular   ligament    being   then 


chap,  xi ii. j    The  Region  of  the  Elboiv.  241 

sufficiently  stretched  to  allow  of  the  complete  dislocation." 
The  biceps  being  relaxed,  the  pronators  act,  and  the 
limb  is  either  pronated  or  assumes  a  position  midway 
between  pronation  and  supination.  Some  stretching 
of  the  supinator  brevis  would  probably  modify  the 
amount  of  pronation.  A  difficulty  in  the  reduction 
is  often  due  to  the  torn  annular  ligament  coming  between 
the  head  of  the  radius  and  the  humeral  condyle. 

Sprain  of  the  elbow. — Mr.  J.  Hutchinson, 
jun.,  has  shown  that  in  young  children,  under  five 
years,  forcible  traction  of  the  limb  in  the  supinated 
position  may  cause  the  radius  to  slip  downwards,  away 
from  the  orbicular  ligament,  which  is  displaced  up- 
wards. Flexion  of  the  elbow  in  the  pronated  position 
restores  the  ligament  to  its  normal  position.  It  is 
clear  that  this  displacement  is  the  anatomical  basis 
of  the  common  sprain  of  the  elbow  met  with  in  young 
children,  and  usually  due  to  violent  traction  of  the 
hand.  The  oblique  ligament,  which  passes  from  the 
ulna  downwards  and  outwards  to  the  radius  below  the 
insertion  of  the  biceps  and  the  supinator  brevis  resists 
such  a  displacement. 

Fractures  of  the  lower  end  of  the  humerus. 
— These  are  :    (1)  A  fracture  just  above  the  condyles  ; 

(2)  "  the    T-shaped    fracture "     involving    the    joint ; 

(3)  fractures  of  the  internal,  and  (4)  of  the  external 
condyle  ;  (5)  fracture  of  the  internal  epicondyle  ;  and 
(6)  separation  of  the  lower  epiphysis.  All  these  frac- 
tures are  more  common  in  the  young. 

1.  The  fracture  "at  the  base  of  the  condyles,"  as 
it  is  sometimes  called,  is  usually  situate  a  little  above 
the  olecranon  fossa,  where  the  humeral  shaft  begins 
to  expand.  It  is  commonly  transverse  from  side  to  side, 
and  oblique  from  behind  downwards  and  forwards. 
It  is  generally  the  result  of  a  blow  inflicted  upon  the 
extremity  of  the  elbow.  Probably  the  tip  of  the  ole- 
cranon driven  sharply  against  the  bone  acts  like  the 
point  of  a  wedge,  and  takes  an  important  share  in  the 
production  of  the  fracture.  The  lower  fragment, 
together  with  the  bones  of  the  fore-arm,  is  generally 

Q 


242  Surgical  Applied  Anatomy.  [Chap.  xm. 

carried  backwards  by  the  triceps,  and  upwards  by  that 
muscle,  the  biceps,  and  the  brachialis  antic  us.  The 
median  or  ulnar  nerves,  especially  the  latter,  may  be 
severely  damaged. 

2.  The  "  T-shaped  fracture  "  is  but  a  variety  of  the 
lesion  just  noted.  In  addition  to  the  transverse  fracture 
above  the  condjdes,  there  is  also  a  vertical  fracture 
running  between  the  two  condyles  into  the  joint.  The 
lower  fragment  is  thus  divided  into  two  parts.  The 
displacement  is  the  same.  The  fracture  is  very  usually 
due  to  a  fall  upon  the  bent  elbow,  and  here  possibly 
also  the  tip  of  the  olecranon  acts  as  a  wedge,  producing 
the  transverse  fracture,  while  the  prominent  ridge 
along  the  middle  of  the  greater  sigmoid  cavity,  acting 
as  a  second  wedge,  produces  the  vertical  fracture  into 
the  joint. 

3,  4,  and  5.  For  surgical  purposes  it  is  well  to  limit 
the  term  "  condyle  "  to  such  parts  of  the  extremity  of 
the  humerus  as  are  within  the  capsule,  and  the  term 
"  epicondyle "  to  such  parts  of  the  lower  projections 
of  the  bone  as  are  without  the  joint. 

In  the  so-called  fracture  of  the  inner  condyle  the 
line  of  separation  generally  commences  about  ^  an  inch 
above  the  tip  of  the  epicondyle  (and,  therefore,  outside 
the  joint),  and  running  obliquely  outwards  through 
the  olecranon  and  coronoid  fossae,  enters  the  articulation 
through  the  centre  of  the  trochlear  surface  (Hamilton). 
The  fragment  is  often  displaced  a  little  upwards,  back- 
wards, and  inwards,  the  ulna  going  with  it. 

In  the  fracture  of  the  external  condyle  the  line  com- 
mences also  above  the  epicondyle  and  outside  the  joint, 
and  running  downwards  enters  the  joint  usually  between 
the  trochlear  surface  and  the  surface  for  the  radius. 
The  displacement  is  trifling  and  inconstant. 

On  account  of  its  insignificant  size,  a  fracture  of 
the  external  epicondyle  is  scarcely  possible.  Fractures 
of  the  inner  epicondyle  are,  however,  quite  common, 
the  joint  remaining  free  (Fig.  31).  This  epicondyle 
exists  as  a  distinct  epiphysis,  which  unites  at  the  age 
of  eighteen,  and  which  at  any  time  before  that  age  may 


Chap,  xiii.]    The  Region  of  the  Elbow. 


243 


be  separated  from  the  bone  by  direct  injury  or  muscular 
violence.  Owing  to  the  dense  aponeurotic  fibres  that 
cover  the  part,  much  displacement  of  the  fragment  is 
uncommon.  When  displacement  exists,  it  is  in  the 
general  line  of  the  common  flexor  muscles  that  arise 
from  the  tip  of  the  process.  In  such  cases  the  ulnar 
nerve,  which  lies  behind  the  process,  is  often  damaged. 


CAP; 


Fie,  31. 


i.  Lower  Epiphysis  of  the  Humerus 
from  behind. 


a,  Centre  for  internal  epicondyle;  b,c,d, 
united  centres  for  the  trochlea,  capi- 
telluni,  and  external  epicondyle; 
e,  k,  epiphyseal  line;  cap.,  lino 
(stippk'dj  at  which  capsule  is  at- 
tached. 


ii.  Section  of  Upper  Extremity  of 
the  Ulna,  showing  the  small  size 
of  its  epiphysis. 

cap.,  Attachment  of  capsule;  o,  epi- 
physis of  olecranon. 


6.  The  lower  epiphysis  (Fig.  31).  The  line  of  this 
epiphysis  is  irregular,  running  across  the  bone 
between  the  tips  of  the  two  condyles.  It  presents 
several  ossific  nuclei,  which,  with  the  exception  of  the 
nucleus  for  the  inner  epicondyle,  unite  with  the  main 
bone  about  the  seventeenth  year.  Thus,  after  the 
age  of  seventeen  the  growth  of  the  bone  must  depend 
upon  the  activity  of  the  upper  epiphysis,  which  does  not 
unite  until  twenty.     Excision  of  the  elbow,  therefore, 


244  Surgical  Applied  Anatomy.  [Chap. xm. 

after  the  sixteenth  or  seventeenth  year,  will  not  be 
followed  by  arrest  of  development  in  the  limb,  even  if 
the  epiphyseal  line  has  been  transgressed  by  the  saw. 
Several  cases  are,  however,  reported  of  marked  arrest 
of  growth  in  the  limb  following  upon  injuries  to  the 
lower  epiphysis  before  the  sixteenth  year,  and  to  the 
upper  epiphysis  before  twenty.  Since  the  epiphyseal 
line  is  almost  wholly  within  the  capsule,  it  follows  that 
but  little  displacement,  other  than  a  slight  movement 
backwards,  is  consequent  upon  the  separation  of  the  mass. 

Fractures  of  the  olecranon  are  commonly  due 
to  direct  violence,  and  in  a  few  cases  to  severe  indirect 
violence  applied  to  the  lower  end  of  the  humerus  or 
upper  end  of  the  ulna.  Instances  of  fracture  by 
muscular  action  are  few,  and  open  to  some  question. 
The  fracture  is  most  commonly  met  with  about  the 
middle  of  the  process,  just  where  it  begins  to  be  con- 
stricted, and  is  usually  transverse  in  direction.  The 
amount  of  displacement  effected  by  the  triceps  varies, 
and  depends  upon  the  extent  to  which  the  dense  peri- 
osteum about  the  process  and  the  ligaments  that  are 
attached  to  it  are  torn.  The  olecranon  is  developed 
mainly  from  the  shaft  of  the  ulna  (Fig.  31).  There  is  a 
small  epiphysis,  however,  at  the  summit  of  the  process 
which  joins  the  rest  of  the  olecranon  at  the  age  of  seven- 
teen. It  is  a  mere  shell  of  bone.  In  young  subjects 
this  scale-like  epiphysis  may  be  separated  by  violence,  or 
the  cartilaginous  olecranon  may  be  dissevered  from  the 
rest  of  the  bone.  The  common  fracture  of  the  adult 
olecranon  does  not  follow  the  epiphyseal  line. 

Fracture  of  the  coronoid  process  is  an 
extremely  rare  accident.  It  is  impossible  to  understand 
how  the  process  can  be  torn  off  by  the  action  of  the 
brachialis  anticus,  as  some  maintain,  since  that  muscle 
is  inserted  rather  into  the  ulna  at  the  base  of  the  projec- 
tion than  into  the  process  itself.  Nor  can  it  be  separated 
as  an  epiphysis,  as  supposed  by  others,  since  it  does  not 
exist  as  such. 

Fractures  of  the  head  or  neck  of  the  radius 
are  rare,  and  occur  usually  with  dislocation  or  other 


Chap,  xin.]    The  Region  oe  the  Elbow.  245 

severe  injury.  The  head  is  commonly  found  split  or 
starred,  and  the  lesion,  if  limited  to  the  head,  could 
hardly  be  diagnosed.  The  upper  epiphysis  of  the  radius 
is  entirely  within  the  limits  of  the  annular  ligament, 
and  could  scarcely  be  separated  in  a  simple  lesion.  It  is 
a  mere  disc  of  cartilage  joining  the  shaft  at  the  age  of 
seventeen.  When  the  neck  is  broken  the  upper  end 
of  the  lower  fragment  is  drawn  well  forwards  by  the 
biceps  muscle. 

Resection  of  the  elbow  may  be  performed  in 
many  ways.  In  all  procedures  there  is  danger  of 
injuring  the  ulnar  nerve,  and  some  little  difficulty 
often  in  clearing  the  prominent  internal  condyle.  If 
the  knife  be  kept  close  to  the  bone,  no  vessel  of  any 
magnitude  should  be  divided.  The  muscles  most  dis- 
turbed are  the  triceps,  anconeus,  supinator  brevis, 
extensor  carpi  ulnaris,  extensor  carpi  radialis  brevior, 
and  brachialis  anticus.  It  is  most  important  to  pre- 
serve the  periosteum  over  the  olecranon,  so  that  the 
triceps  may  still  have  some  attachments  to  the  fore- 
arm. It  is  never  necessary  to  divide  the  insertion  of 
the  brachialis  anticus,  still  less  of  the  biceps,  although 
some  few  fibres  of  the  former  muscle  may  be  separated 
in  removing  the  upper  surface  of  the  ulna.  By  the 
subperiosteal  method  the  periosteum  is  carefully  peeled 
off  from  all  the  parts  to  be  resected,  and  is  preserved. 
By  this  means  the  triceps  retains  a  hold  upon  the  ulna, 
and  the  restoration  of  the  joint  is  more  complete.  The 
functions  of  the  joint  may  be  well  restored  after  re- 
section, especially  when  performed  by  the  subperiosteal 
method,  but  it  would  appear  that  after  no  method 
are  the  anatomical  details  of  the  joint  reproduced.  Thus, 
in  a  successful  case,  the  new  joint  will  assume  the  bi- 
malleolar  form,  and  will  resemble  the  ankle  rather  than 
the  elbow  joint.  The  humerus  throws  out  two  malleoli 
on  the  sites  of  the  normal  condyles,  and  in  the  concavity 
between  them  the  ulna  and  radius  are  received.  Be- 
tween the  ulna  and  the  humerus  new  ligaments  form 
and  a  new  annular  ligament  for  the  radius  is  also 
developed. 


246 
CHAPTER    XIV. 

THE   FOEE-AEM. 

Surface    anatomy. — At    its    upper    half,    and 

especially  in  its  upper  third,  the  limb  is  much  wider 
in  its  transverse  than  in  its  antero-posterior  diameter. 
A  horizontal  section  through  this  part  will  show  a  cut 
surface  that  is  somewhat  oval  in  outline,  and  is  at  the 
same  time  flattened  in  front  and  more  convex  behind. 
This  outline  is  best  seen  in  muscular  subjects,  and  depends 
chiefly  upon  the  development  of  the  lateral  masses  of 
muscle  that  descend  from  the  condyles.  In  the  non- 
muscular,  the  limb,  even  in  its  highest  parts,  tends  to 
assume  a  rounded  rather  than  an  oval  outline.  In 
women  and  children,  also,  the  limb  is  round,  owing  to  the 
comparatively  slight  development  of  the  lateral  muscular 
masses,  and  to  the  accumulation  of  fat  on  the  front  and 
back  of  the  limb.  The  posterior  surface  of  the  fore-arm 
in  a  vigorous  subject  presents  along  its  outer  border 
a  prominence  formed  by  the  supinator  longus  and  the 
two  radial  extensors,  which  become  tendinous  below  the 
centre  of  that  border.  On  the  lower  third  of  this  edge 
is  a  slight  eminence,  directed  obliquely  downwards, 
outwards  and  forwards,  and  due  to  the  crossing  of  the 
extensors  of  the  thumb.  In  the  middle  of  the  posterior 
surface  is  another  elevation,  running  down  from  the 
outer  condyle,  and  formed  mainly  by  the  extensor 
communis.  To  the  inner  side  of  this  eminence  is  a 
groove,  well  seen  in  the  very  muscular,  that  indicates 
the  posterior  border  of  the  ulna.  The  ulna  is  subcu- 
taneous throughout  its  entire  extent,  and  can  be  readily 
examined.  The  upper  half  of  the  radius  is  too  deeply 
placed  to  be  well  made  out,  but  the  lower  half  of  the 
bone  can  be  easily  felt  beneath  the  skin.  The  course  of 
the  radial  artery  is  represented  by  a  line  drawn  from 
the  outer  border  of  the  biceps  tendon  at  the  bend  of  the 
elbow  to  a  point  in  front  of  the  styloid  process  of  the 
radius.     The  pulse  is  felt  between  the  styloid  process 


Chap,  xiv.]  The  Fore-arm.  247 

and  tendon  of  the  flexor  carpi  radialis  wheie  the  artery 
rests  on  the  lower  extremity  of  the  radius.  The  middle 
and  lower  thirds  of  the  ulnar  artery  follow  a  line  from 
the  inner  condyle  to  the  radial  side  of  the  pisiform  bone. 
The  upper  third  would  be  represented  by  a  line  drawn 
from  the  middle  of  the  bend  of  the  elbow  to  meet  the  first 
line  at  the  junction  of  the  upper  and  middle  thirds 
of  the  inner  border  of  the  fore-arm.  Such  a  line  would 
be  slightly  curved,  with  its  concavity  outwards.  The 
tendons,  etc.,  that  can  be  demonstrated  at  the  lower 
extremity  of  the  fore-arm  will  be  considered  in  the 
description  of  the  wrist. 

Vessels. — It  is  well  to  note  the  very  free  anasto- 
moses that  exist  along  the  greater  part  of  the  limb 
between  the  ulnar  and  radial  arteries.  This  fact  was 
illustrated  by  a  case  under  my  care,  some  time  ago,  in 
the  London  Hospital.  A  seaman  had  inflicted  upon 
his  left  fore-arm  three  deep  transverse  wounds  across 
the  front  of  the  limb  with  a  sharp  knife.  The  wounds 
were  about  \\  inches  apart.  The  radial  artery  was 
divided  in  each  of  the  wounds,  and  that  vessel,  there- 
fore, presented  six  cut  ends.  It  would  appear  to  be 
sufficient  to  ligature  the  proximal  and  distal  ends  of 
the  wounded  vessel,  and  to  leave  the  two  isolated  por- 
tions of  the  artery,  each  about  \\  inches  in  length, 
alone.  I  applied  ligatures  to  five  of  the  divided  ends, 
leaving  the  lower  end  of  the  upper  isolated  piece  of 
the  artery  untied,  and  watched  the  effect.  During  the 
course  of  the  day,  when  the  man  had  rallied  from  the 
profound  faintness  due  to  the  great  less  of  bloccl  he 
had  experienced,  copious  bleeding  took  place  from  this 
single  unsecured  end  of  the  vessel,  and  it,  of  course, 
had  also  to  be  tied. 

There  is  a  singular  absence  of  large  blocd-vessels 
or  nerves  along  the  posterior  aspect  of  the  fore-arm, 
and  it  is  significant  that  this  is  the  aspect  of  the  limb 
most  exposed  to  injury.  For  a  hands-breadth  below 
the  olecranon  there  is  almost  an  entire  absence  of 
superficial  veins. 

The  median  neive  passes  between  the  two  heads 


248 


Surgical  Applied  Anatomy.   [Chap.  xiv. 


of  the  pronator  teres,  and  may  possibly  be  compressed 
by  that  muscle  when  in  vigorous  action.  In  this  way 
may  be,  perhaps,  explained  the  cramp  on  the  flexor 
side  of  the  limb  that  sometimes  occurs  after  certain 
violent  exercises.  The  amount  of  muscular  tissue  in  the 
deep  head  of  the  muscle  varies  considerably. 

The  bones  of  the  fore-arm. — Transverse  sections 
of  the  limb  at  various  levels  show  that  the  radius  and 

ulna  are  in  all  parts 
7  nearer  to  the  posterior 

than  the  anterior 
aspect  of  the  extremity 
(Figs.  32  and  33). 
This  relation  is  the 
more  marked  the 
higher  up  the  section. 
The  two  bones  are 
nearest  to  the  centre 
of  the  limb  about  the 
lower  end  of  the 
middle  third.  At  the 
upper  part  of  the  fore- 
arm the  muscles  are 
found  mainly  at  the 
sides  and  in  front. 
The  lower  the  section 
proceeds     down     the 

profundus' digitorum.;  >,. extensor  carpi  lj^V,  the  less  will  the 
ulnaris;  I,  extensor  indicis ;  w,  extensor  umui  lliC  ie&!5  Wlil  W1C 
minimi  digiti ;  n,  extensor  communis  cdgi-     bones    be     Covered     at 

the  sides,  and  the 
more  equally  will  the 
soft  parts  be  found 
distributed  about  the 
anterior  and  posterior  aspects  of  the  limb.  It  will  be 
noticed  that  where  one  bone  is  the  most  substantial  the 
other  is  the  most  slender,  as  near  the  elbow  and  wrist ; 
and  that  it  is  about  the  centre  of  the  limb  that  the 
two  are  most  nearly  of  equal  strength.  The  proximity 
of  the  two  bones,  and  especially  of  the  ulna,  to  the 
posterior  aspect  of  the  limb  permits  them  to  be  easily 


Fig.  32.— A  Transverse  Section  through, 
the  middle  of  the  Fore-arm  (Braune). 

a  Radius;  b,  ulna;  c,  supinator  longus ;  d, 
flexor  lonsrus  pollicis:  e,  flexor  carpi  radi- 
alis  ;  /,  palmans  longus  ;  g,  flexor  sublimis 
digitorum;  h,  flexor  carpi  ulnaris ;  i,  flexor 


toriu  ;  o,  extensor  ossis  and  extensor 
secundi  internodii  pollicis;  q,  extensor 
carpi  vadialis  brevior  ;  r,  extensor  carpi 
radial  is  longior  :  s,  pronator  radii  teres ; 
1,  radial  vessels  and  nerve  ;  2,  ulnar  vessels 
and  nerve. 


chap,  xiv.]  The  Fore-arm.  249 

examined  from  that  surface,  while  it  is  from  the  same 
aspect  that  resections  and  other  operations  upon  the 
bones  are  most  readily  performed.  It  will  be  under- 
stood, moreover,  that  in  compound  fractures,  due  to 
penetration  of  fragments,  the  wound  is  more  usually 
on  the  posterior  aspect  of  the  limb. 

The  important  movements  of  pronation  and  supi- 
nation take  place  between  these  bones,  and  round  an 
axis  corresponding  to  a  line  drawn  through  the  head 
of  the  radius,  the  lower  end  of  the  ulna,  and  the  meta- 
carpal bone  of  the  ring-finger.  Pronation  is  mainly 
checked  by  the  lower  and  middle  parts  of  the  interosseous 
membrane,  the  posterior  radio-ulnar  ligament,  the  inner 
part  of  the  posterior  ligament  of  the  wrist,  and  the 
opposition  of  the  bones.  Supination  is  chiefly  limited 
by  the  lowest  fibres  of  the  interosseous  membrane,  the 
anterior  radio-ulnar  ligament,  and  the  internal  lateral 
ligament  of  the  wrist.  "  The  chief  influence  in  checking 
supination  is  not  to  be  found  in  ligament  at  all,  but 
in  the  contact  of  the  posterior  edge  of  the  sigmoid  cavity 
of  the  radius  with  the  tendon  of  the  extensor  carpi 
ulnaris,  as  it  lies  in  the  groove  between  the  styloid  process 
and  the  round  head  of  the  ulna  "  (H.  Morris).  Of  the 
two  movements,  supination  is  the  more  powerful.  This 
is  illustrated  in  many  ways.  In  using  a  screw-driver 
or  a  gimlet  the  movements  of  pronation  and  supination 
are  conspicuously  involved,  but  the  main  force  is  applied 
during  supination.  It  is  significant  that  the  thread 
of  a  corkscrew  is  so  turned  that  it  shall  be  inserted  by 
supination  rather  than  by  pronation. 

The  only  position  in  which  the  two  bones  are  parallel 
to  one  another  is  in  the  mid-position  between  pronation 
and  supination.  It  is  in  this  posture  only  that  the 
interosseous  membrane  is  uncoiled  throughout.  Hence 
the  selection  of  this  position  in  the  adjustment  of  most 
fractures  of  the  fore-arm.  The  interosseous  space  is 
an  irregular  ellipse,  a  little  larger  below  than  above. 
It  is  narrowest  in  full  pronation,  widest  in  supination, 
and  nearly  as  wide  in  the  mid-position. 

It   may  be   noted  that   the  oblique  ligament   tends 


250  Surgical  Applied  Anatomy.   [Chap.  xiv. 

to  resist  forces  that  would  drag  the  radius  away  from 
the  humerus,  and  takes  the  place  and  the  function  of 
a  direct  ligament,  passing  from  the  humerus  to  the 
radius,  while  the  interosseous  membrane,  from  the 
obliquity  of  its  fibres,  makes  the  ulna  take  a  share  in 
the  strain  put  upon  the  radius  when  that  bone  is  forced 
upwards,  as  in  resting  on,  or  pushing  with,  the  palm. 

Fractures  of  the  forewarn!. — The  two  bones 
are  more  often  broken  together  than  is  either  the  radius 
or  the  ulna  alone.  The  radius,  when  broken  alone, 
is  usually  fractured  by  indirect  violence,  since  it  receives 
more  or  less  entirely  all  shocks  transmitted  from  the 
hand.  The  ulna,  on  the  contrary,  is  more  often  broken 
by  direct  violence,  it  being  the  more  superficial  and 
exposed  of  the  two  bones.  For  example,  in  raising 
the  arm  to  ward  off  a  blow  from  the  head,  the  ulna 
becomes  uppermost.  When  the  two  bones  are  broken 
together,  the  violence  may  be  direct  or  indirect. 
Malgaigne  reports  a  case  where  both  bones  were  broken 
by  muscular  violence  in  a  patient  while  shovelling 
earth.  Here  the  bones  probably  were  broken  between 
the  two  opposed  forces  represented  by  the  biceps  and 
brachialis  anticus  above  and  the  weight  of  the  loaded 
shovel  in  the  hand  below.  When  both  bones  are  broken 
and  the  fractures  are  oblique,  shortening  may  be  pro- 
duced by  the  united  action  of  the  flexors  and  extensors. 
The  displacement  varies  greatly,  and  depends  rather 
upon  the  direction  of  the  violence  than  upon  muscular 
action.  Thus  Hamilton  says  :  "  I  have  seen  the  frag- 
ments deviate  slightly  in  almost  every  direction."  If 
union  be  delayed,  the  delay  is  usually  in  the  radius, 
since  it  is  the  more  mobile  of  the  two  bones.  When 
the  radius  alone  is  broken  (1)  between  the  insertions 
of  the  biceps  and  pronator  teres,  the  upper  fragment 
is  flexed  by  the  biceps  ^and  fully  supinated  by  that  muscle 
and  the  small  supinator.  The  lower  fragment  will  be 
pronated  by  the  two  pronators,  and  drawn  in  towards 
the  ulna  by  means  of  those  muscles.  If  such  a  fracture 
be  put  up  with  the  hand  midway  between  the  prone 
and  supine  position,  the  following  evils  result  :  the  upper 


Chap.  xiv.  The  Fore-arm.  251 

fragment  is  fully  supinated  by  the  muscles  ;  the  lower 
fragment  is  placed  in  the  mid-position  by  the  splints. 
It  follows  that  the  proper  axis  of  the  bone  is  not  repro- 
duced, and  the  use  of  the  biceps  and  supinator  brevis 
as  supinators  is  entirely  lost.  Thus  patients  so  treated 
usually  recover  with  great  loss  in  the  power  of  supination  ; 
and  to  avoid  this  ill  result,  it  is  advised  to  put  the  limb 
up  in  full  supination,  so  that  the  two  fragments  may 
unite  in  their  proper  axis,  the  upper  fragment  being 
supinated  by  the  muscles,  the  lower  by  the  splints. 
(2)  When  the  fracture  is  between  the  insertions  of  the 
two  pronators,  the  upper  fragment  may  be  carried 
a  little  forwards  by  the  biceps  and  pronator  teres,  and 
drawn  towards  the  ulna  by  the  latter  muscle.  The 
bone  will  probably  be  in  the  mid-position,  the  two 
supinators  (biceps  and  supinator  brevis)  attached  to 
the  fragment  being  more  or  less  neutralised  by  the 
pronator  that  is  also  connected  with  it.  The  lower 
fragment  will  be  adducted  to  the  ulna  by  the  pronator 
quadratus,  and  its  upper  end  will  be  still  further  tilted 
towards  that  bone  by  the  action  of  the  supinator  longus 
upon  the  styloid  process.  When  the  ulna  is  broken 
alone,  as,  for  example,  about  its  middle,  the  upper  frag- 
ment may  be  drawn  a  little  forwards  by  the  brachialis 
anticus,  while  the  lower  fragment  will  be  carried  towards 
the  radius  by  the  pronator  quadratus. 

The  displacement,  however,  in  all  cases  is  influenced 
as  much  by  the  direction  of  the  violence  as  by  the  action 
of  muscles.  When  the  fragments,  after  fracture  of 
one  or  of  both  bones,  fall  in  towards  one  another,  so 
as  to  meet  across  the  interosseous  space,  attempts  are 
sometimes 'made  to  separate  the  broken  ends  and  to 
preserve  the  integrity  of  the  space  by  the  use  of  graduated 
pads.  These  pads,  however,  if  supplied  with  sufficient 
force  to  separate  the  fragments,  will  probably  compress 
one  or  both  of  the  arteries  of  the  limb,  and  cause  great 
distress  by  pressure  upon  the  median  nerve. 

The  fact  that  the  bulk  of  the  venous  blood  of  the 
fore-arm  is  returned  by  surface  veins  may  explain  the 
ready  occurrence  of  severe  oedema  in  the  limb  when 


252 


Surgical  Applied  Anatomy.    [Chap.  xiv. 


fractures  are  treated  with  improperly  applied  splints 
or  bandages.  Since  the  arteries  also  can  be  readily 
affected  by  pressure,  it  follows  that  gangrene  of  the 
limb,  as  a  result  of  improper  treatment,  is  more  common 
after  fracture  of  the  fore-arm  than  after  fracture  in  any 
other  part. 

Amputation  of  the  fore-arm. — In    amputa- 
tion of  the  fore-arm  by  double  transfixion  flaps,  at  about 

the  upper  part  of  the 
middle  third  the  parts 
would  be  cut  in  the  follow- 
ing manner  :  On  the  face 
of  the  anterior  flap  would 
be  seen  from  without  in- 
wards the  supinator  longus 
(cut  the  whole  length  of 
the  flap),  then  the  flexor 
sublimis  (cut  to  a  like 
extent),  and,  lastly,  the 
flexor  carpi  ulnaris.  Be- 
tween the  supinator  longus 
and  the  flexor  sublimis 
the  divided  end  of  the 
pronator  teres  is  seen ;  and 
between  the  flexor  sublimis 
and  the  skin  would  lie  the 
flexor  carpi  radialis  and 
the  palmaris  longus.  The 
latter  would  appear  as  a 
tendon  at  the  inner  border 
of  the  flap.  In  the  angle  be- 
tween the  two  flaps  would 
be  found  in  front  of  the  radius  a  little  of  the  flexor  longus 
pollicis,  and  in  front  of  the  ulna,  the  flexor  profundus, 
the  latter  cut  much  the  longer.  Quite  close  to  the  radius, 
and  for  the  most  part  behind  it,  would  be  the  lowest 
part  of  the  small  supinator,  while  behind  the  ulna  would 
be  the  cut  fibres  of  the  upper  end  of  the  extensor  ossis. 
On  the  face  of  the  posterior  flap  would  be  see nT from 
without    inwards    the    extensor    carpi    radialis    longior 


Fig.  33  — A  Transverse  Section 
through  the  lower  third  of  the 
Fore-arm.     (Braune). 

a,  Radius ;  6,  ulna ;  c,  supinator  longus  : 
d,  flexor  longus  pollicis ;  c,  flexor 
carpi  radialis;  /,  palmaris  longus 
g,  flexor  sublimis  digitorum ;  h 
flexor  carpi  ulnaris ;  i,  flexor  pro 
fundus  digitorum  ;j,  pronator  quad 
ratus ;    k,  extensor  carpi   ulnaris 

1,  extensor  indicis ;  ra,  extensor 
minimi  digiti ;  n,  extensor  com- 
munis digitorum;  o,  extensor  se- 
cundi  internodii  pollicis;  p,  exten- 
sor primi  internodii  pollicis;  q, 
extensor  carpi  radialis  brevier  ;  r, 
extensor  carpi  radialis  longior.with. 
in  front  of  it,  the  extensor  ossis 
metacarpi  pollicis;  l,  radial  vessels: 

2,  ulnar  vessels  ;  3,  median  nerve. 


chap,  xv.j  The  Wrist  and  Hand.  253 

and  brevior,  the  extensor  communis,  the  extensor  of 
the  little  finger,  and  the  extensor  carpi  ulnaris.  The 
radial  artery  will  run  the  whole  length  of  the  anterior 
flap,  and  be  cut  near  its  outer  border  to  the  inner  side 
of  the  supinator  longus.  The  ulnar  artery  will  be  cut 
shorter,  will  be  in  front  of  the  bone,  and  between  the 
flexor  sublimis  and  flexor  profundus.  The  anterior 
interosseous  vessels  will  be  divided  immediately  in  front 
of  the  interosseous  membrane.  The  posterior  inter- 
osseous vessels  will  be  cut  long,  and  will  be  found  between 
the  superficial  and  deep  muscles. 

Fig.  33  shows  the  relation  of  the  parts  as  they  would 
be  cut  in  a  circular  amputation  of  the  limb  through 
the  lower  third. 


CHAPTER    XV. 

THE   WRIST    AND    HAND. 

Surface  anatomy. — The  following  structures 
can  be  made  out  about  the  wrist :  Commencing  at 
the  outer  side,  the  lower  extremity  and  styloid  process 
of  the  radius  can  be  well  defined.  The  bone  is  here 
superficial  in  front  and  behind.  The  styloid  process 
lies  more  anteriorly  than  does  the  corresponding  process 
of  the  ulna,  and  also  descends  about  \  an  inch  lower 
down  the  limb.  The  outer  surface  of  the  radius  at  the 
wrist  is  crossed  by  the  tendons  of  the  extensor  ossis 
metacarpi  and  extensor  brevis  pollicis.  These  are  very 
distinct  when  the  thumb  is  abducted,  and  the  slit-like 
interval  between  the  two  can  be  felt.  About  the  centre 
of  the  front  of  the  wrist  is  the  palmaris  longus  tendon, 
which  is  usually  the  most  conspicuous  of  the  tendons 
on  this  aspect  of  the  joint.  It  will  be  found  absent  in 
quite  10  per  cent,  of  wrists  examined.  It  is  rendered 
most  prominent  when  the  wrist  is  a  little  flexed,  the 
fingers  and  thumbs  extended,  and  the  thenar  and  hypo- 
thenar  eminences  as  much  approximated  as  possible. 
A  little  to  its  outer  side  is  the  larger  but  less  prominent 


254  Surgical  Applied  Anatomy.     [Chap.  xv. 

tendon  of  the  flexor  carpi  radialis.  In  the  narrow  groove 
between  these  two  tendons  lies  the  median  nerve,  and 
on  the  radial  side  of  the  flexor  carpi  radialis  is  the  radial 
artery.*  The  vense  comites  surround  the  artery,  and 
when  distended  alter  the  character  of  the  pulse  (Hill). 
Towards  the  inner  border  of  the  wrist  the  flexor  carpi 
ulnaris  tendon  is  evident,  descending  to  the  pisiform 
bone.  It  is  rendered  most  distinct  when  the  wrist  is 
slightly  flexed  and  the  little  finger  pressed  forcibly 
into  the  palm.  In  the  hollow  which  this  posture  pro- 
duces between  the  last-named  tendon  and  the  palmaris 
longus  lie  the  flexor  sublimis  tendons,  and  just  to  the 
radial  side  of  the  flexor  carpi  ulnaris  the  pulsations 
of  the  ulnar  artery  can  be  felt.  Beneath  the  thin  skin 
in  front  of  the  wrist  a  part  of  the  plexus  of  veins  can 
be  seen  that  end  in  the  median  and  anterior  ulnar  trunks. 
The  ulnar  nerve  grooves  the  radial  side  of  the  pisiform  bone. 
At  the  back  of  the  wrist  the  following  tendons  can 
be  readily  distinguished  from  without  inwards  :  the 
extensor  longus  pollicis  (extensor  secundi  internodii), 
the  extensor  communis,  and  the  extensor  carpi  ulnaris. 
Of  these,  the  most  prominent  is  the  first-named.  It 
is  rendered  most  distinct  when  the  thumb  is  forcibly 
abducted  and  extended.  The  tendon  leads  up  to  a 
small  but  prominent  bony  elevation  on  the  back  of 
the  radius  that  marks  the  outer  border  of  the  osseous 
groove  for  its  reception.  This  tendon,  when  it  reaches 
the  radius,  points  to  the  centre  of  the  posterior  surface 
of  that  bone,  and  indicates  also  roughly  the  position 
of  the  interval  between  the  scaphoid  and  semilunar 
bones.  The  lower  end  of  the  ulnar  is  very  distinct. 
When  the  hand  is  supine,  its  styloid  process  is  exposed 
at  the  inner  and  posterior  aspect  of  the  wrist  to  the 
inner  side  of  the  extensor  carpi  ulnaris.  In  pronation, 
however,  the  process  is  rendered  less  distinct,  while 
the  head  projects  prominently  on  the  posterior  part  of 

*  Sometimes  the  superficialis  volae  arises  higher  and  is  larger 
than  usual.  It  then  runs  by  the  side  of  the  radial  in  front  of  the 
wrist,  and,  giving  additional  volume  to  the  pulse,  has  been  the 
foundation  of  the  so-called  "  double  pulse." 


chap,  xv.j  The   Wrist  and  Hand.  255 

the  wrist,  and  is  found  to  lie  between  the  tendons  of 
the  extensor  carpi  ulnaris  and  extensor  minimi  digiti. 

The  ivrist  joint. — The  tip  of  the  styloid  process  of 
the  ulna  corresponds  to  the  line  of  the  wrist  joint,  and 
a  knife  entered  below  that  point  would  enter  the  articu- 
lation. A  knife  entered  horizontally  just  below  the  tip 
of  the  styloid  process  of  the  radius  would  hit  the  scaphoid 
bone.  A  line  drawn  between  the  two  styloid  processes 
would  slope  downwards  and  outwards,  its  two  extremities 
would  represent  the  extreme  inferior  limits  of  the  radio- 
carpal joint,  and  would  fairly  correspond  to  the  chord 
of  the  arc  formed  by  the  line  of  that  joint.  The  line 
between  the  styloid  processes  would  be  nearly  h  an  inch 
below  the  summit  of  the  arch  of  the  wrist  joint. 

There  are  several  folds  in  the  skin  on  the  front  of 
the  wrist ;  of  these,  the  lowest  is  the  most  distinct. 
It  is  a  little  convex  downwards,  precisely  crosses  the 
neck  of  the  os  magnum  in  the  line  of  the  third  meta- 
carpal bone  (Tillaux),  and  is  not  quite  f  of  an  inch  below 
the  arch  of  the  wrist  joint.  It  is  about  \  an  inch  above 
the  carpo-metacarpal  joint  line,  and  indicates  very  fairly 
the  upper  border  of  the  anterior  annular  ligament. 

The  palmar  surface  of  hand. — The  palm  is  concave 
in  the  centre  where  the  skin  is  adherent  to  the  palmar 
fascia.  This  "  hollow  of  the  hand "  is  of  somewhat 
triangular  outline,  with  the  apex  upwards.  On  either 
side  are  the  thenar  and  hypothenar  eminences.  At 
the  upper  end  of  the  former  eminence,  a  bony  projection 
is  felt,  just  below  and  internal  to  the  radial  styloid 
process,  that  is  formed  by  the  tubercle  of  the  scaphoid 
and  ridge  on  the  trapezium.  The  interval  separating 
these  two  processes  of  bone  cannot  always  be  made  out. 
At  the  upper  extremity  of  the  hypothenar  eminence 
is  the  projection  of  the  pisiform  bone,  and  just  below 
it  the  unciform  process  can  be  identified.  Below  the 
hollow  of  the  palm,  and  opposite  the  clefts  between  the 
four  fingers,  three  little  elevations  are  seen,  especially 
when  the  first  phalanges  are  extended,  and  the  second 
and  third  are  flexed.  These  correspond  to  the  fatty 
tissue  between  the  flexor  tendons  and  the  digital  slips 


256 


Surgical  Applied  Anatomy.     [Chap.  xv. 


of  the  palmar  fascia.     The  grooves  that  may  he  seen 
to  separate  the  elevations  correspond  to  those  slips. 


Fig.  34. — Surface  Markings  on  the  Palm  of  the  Hand. 
The  thick  black  lines  represent  the  chief  creases  on  the  skin. 

Of  the  many  creases  in  the  skin  of  the  palm  three 
require  especial  notice.  The  first  starts  at  the  wrist, 
between  the   thenar  and  hypothenar  eminences,   and 


Chap,  xv.j  The    Wrist  and  Hand.  257 

marking  off  the  former  eminence  from  the  palm  ends 
at  the  outer  border  of  the  hand  at  the  base  of  the  index 
finger.  The  second  fold  is  slightly  marked.  It  starts 
from  the  outer  border  of  the  hand,  where  the  first  fold 
ends.  It  runs  obliquely  inwards  across  the  palm  with 
a  marked  inclination  towards  the  wrist,  and  ends  at  the 
outer  limit  of  the  hypothenar  eminence.  The  third, 
lowest,  and  best-marked  of  the  folds  starts  from  the 
little  elevation  opposite  the  cleft  between  the  index 
and  middle  fingers,  and  runs  nearly  transversely  to  the 
ulnar  border  of  the  hand,  crossing  the  hypothenar 
eminence  at  the  upper  end  of  its  lower  fourth.  An 
unimportant  crease  running  obliquely  from  the  third 
to  the  second  fold  gives  to  these  markings  the  outline 
of  the  letter  M.  The  first  fold  is  produced  by  the 
opposition  of  the  thumb,  the  second  mainly  by  the 
bending  simultaneously  of  the  metacarpophalangeal 
joints  of  the  first  and  second  fingers,  and  the  third  by 
the  flexion  of  the  three  inner  fingers.  The  second  fold, 
as  it  crosses  the  third  metacarpal  bone,  about  corre- 
sponds to  the  lowest  point  of  the  superficial  palmar  arch. 
The  third  fold  crosses  the  necks  of  the  metacarpal  bones, 
and  indicates  pretty  nearly  the  upper  limits  of  the 
synovial  sheaths  for  the  flexor  tendons  of  the  three 
outer  fingers.  A  little  way  below  this  fold  the  palmar 
fascia  breaks  up  into  its  four  slips,  and  midway  between 
the  fold  and  the  webs  of  the  fingers  lie  the  metacarpo- 
phalangeal joints.  Of  the  transverse  folds  across  the 
fronts  of  the  fingers  corresponding  to  the  metacarpo- 
phalangeal and  phalangeal  joints,  the  highest  is  single 
for  the  index  and  little  finger  and  double  for  the  other 
two.  It  is  placed  nearly  f  of  an  inch  below  the  corre- 
sponding joint.  The  middle  folds  are  double  for  all 
the  fingers,  and  are  exactly  opposite  the  first  inter- 
phalangeal  joints.  The  lowest  creases  are  single,  and 
are  placed  a  little  above  the  corresponding  joints  (1  to 
2  mm.,  according  to  Paulet).  There  are  two  single 
creases  on  the  thumb  corresponding  to  the  two  joints, 
the  higher  crossing  the  metacarpophalangeal  articula- 
tion obliquely.     The  free  edge  of  the  web  of  the  fingers, 


258  Surgical  Applied  Anatomy.     [Chap.  xv. 

as  measured  from  the  palmar  surface,  is  about  f  of  an 
inch  from  the  metacarpophalangeal  joints.  The  super- 
ficial palmar  arch  may  be  represented  by  a  curved  line 
across  the  palm  starting  from  the  pisiform  bone  and 
running  in  a  line  with  the  palmar  border  of  the  thumb 
when  outstretched  at  right  angles  with  the  index  finger. 
The  deep  arch  is  between  \  and  \  an  inch  nearer  the 
wrist,  and  its  position  may  be  accurately  marked  by  a 
line  drawn  from  the  base  of  the  fifth  metacarpal  to  the 
base  of  the  second.  The  digital  arteries  bifurcate  about 
\  an  inch  above  the  clefts  between  the  fingers. 

The  dorsal  surface  of  the  hand. — On  the  outer  side 
of  the  wrist,  when  the  thumb  is  extended,  a  hollow  is 
obvious  between  the  extensores  ossis  metacarpi  and 
brevis  pollicis  and  the  extensor  longus  pollicis.  French 
writers  have  termed  this  hollow  "  tabatiere  anatomique." 
Across  this  hollow  and  beneath  the  tendons  just  named 
runs  the  radial  artery.  Under  the  skin  over  the  space 
can  usually  be  seen  a  large  vein,  the  cephalic  vein  of  the 
thumb.  Across  the  space  also  runs  the  internal  division 
of  the  terminal  branch  of  the  radial  nerve.  In  the 
floor  of  the  "  snuff-box  "  are  the  scaphoid  bone  and  the 
trapezium.  The  extensor  longus  pollicis  crosses  the 
apex  of  the  first  interosseous  space.  The  sesamoid 
bones  of  the  thumb  and  the  joint  between  the  trapezium 
and  the  first  metacarpal  bone  can  all  be  well  made  out. 
The  latter  articulation  is  situate  on  the  floor  of  the 
"  tabatiere."  On  the  back  of  the  hand  the  various 
tendons  and  the  surface  veins,  too,  can  all  be  clearly 
distinguished.  Between  the  first  and  second  meta- 
carpal bones  is  the  first  dorsal  interosseous  muscle, 
which  forms  a  conspicuous  prominence  when  the 
thumb  is  pressed  against  the  side  of  the  index  finger. 
The  three  rows  of  knuckles  are  formed  by  the  proximal 
bones  of  the  several  joints. 

The  wrist  and  hand. — The  skin  of  the  palm 
and  of  the  front  of  the  fingers  is  thick  and  dense,  while 
that  on  the  back  of  the  hand  is  much  finer.  The  palm, 
the  fronts,  and  sides  of  the  fingers,  and  the  dorsal  aspects 
of  the  last  phalanges,  all  show  an  entire  absence  of  hair 


chap.  xv. j  The   Wrist  and  Hand.  259 

and  of  sebaceous  glands.  These  parts  are,  therefore, 
exempt  from  the  maladies  that  attack  hair  follicles  and 
their  gland  appendages.  On  the  dorsum  of  the  hand, 
and  of  the  first  and  second  rows  of  phalanges,  there 
are  numerous  hairs  and  sebaceous  follicles.  Sweat 
glands  are  more  numerous  in  the  skin  of  the  palm  than 
in  any  other  part.  According  to  Sappey  they  are  four 
times  more  numerous  here  than  they  are  elsewhere. 
Krause  has  estimated  that  nearly  2,800  of  these  glands 
open  upon  a  square  inch  of  the  palm.  Only  about  half 
the  number  are  found  upon  the  dorsum  of  the  hand. 
The  profuse ness  with  which  the  palm  may  perspire  is 
well  known,  and  is  very  marked  in  certain  conditions. 
The  cutaneous  nerve-supply  of  the  hand  is  very  free. 
The  nerves  present  Pacinian  bodies,  which  are  far  more 
numerous  in  the  hand  than  in  any  other  part,  and  in 
no  portion  of  the  surface  are  tactile  corpuscles  more 
numerous  or  more  highly  developed.  With  the  excep- 
tion of  the  tip  of  the  tongue,  a  more  acute  degree  of 
tactile  sensibility  is  met  with  in  the  hand  than  in  any 
other  part.  The  most  sensitive  district  is  the  palmar 
surface  of  the  third  phalanx  of  the  index  finger,  while 
the  least  sensitive  to  tactile  impressions  is  the  dorsum 
of  the  hand.  It  may  be  said  that  the  tips  of  the  fingers 
are  about  thirty  times  more  acute  to  the  sense  of  touch 
than  is  the  skin  of  the  middle  of  the  fore-arm,  which 
is  among  the  least  sensitive  portions  of  the  integument 
as  regards  tactile  influences. 

The  subcutaneous  tissue  of  the  front  of  the  hand, 
and  especially  of  the  palm,  is  scanty  and  dense,  and 
somewhat  resembles  the  subcutaneous  tissue  of  the 
scalp  in  that  the  skin  is  closely  adherent  to  it,  and  the 
fat  it  contains  is  arranged  in  minute  lobules  lodged  in 
lacunae.  Cutaneous  ligaments  bind  the  skin  down  at 
the  creases  of  the  palm  and  fingers.  The  subcutaneous 
tissue  on  the  dorsum  is,  on  the  other  hand,  lax,  and 
has  but  a  frail  association  with  the  skin.  Thus  it  follows 
that  subcutaneous  extravasations  of  blood  are  practic- 
ally impossible  in  the  palm  and  on  the  anterior  aspect 
of  the  ringers,  while  they  may  be  very  extensive  on  the 


260  Surgical  Applied  Anatomy.     [Chap.  xv. 

dorsum.  In  like  manner  oedema  of  the  extremity  is 
conspicuously  marked  upon  the  dorsal  surface,  while 
the  palm  remains  comparatively  free  even  in  severe 
cases.  Surface  inflammations  also  of  the  dorsum  are 
attended  with  considerable  swelling,  while  those  of  the 
front  of  the  hand  show  no  such  feature.  At  the  same 
time  the  adhesion  of  the  palmar  integument  to  the 
deeper  parts  is  so  close  that  surface  wounds  do  not  gape, 
and  are  in  a  position  to  encourage  ready  healing.  The 
denseness  of  the  integuments  of  the  palm  renders  in- 
flammation of  the  part  extremely  painful,  owing  to  the 
tension  that  is  so  readily  produced,  whereas  inflam- 
mation in  the  lax  tissues  of  the  dorsum  may  reach 
some  magnitude  without  causing  great  pain.  The  palm 
of  the  hand  is  well  adapted  to  meet  the  effects  of  pressure 
and  friction.  The  cuticle  is  thick,  the  skin  is  adherent, 
and  immediately  beneath  it  lies  the  dense  palmar  fascia. 
This  fascia  efficiently  protects  the  palmar  nerves  and 
the  main  vessels,  while  it  must  be  noted  that  the  front 
of  the  hand,  and  especially  the  palm,  is  singularly  free 
from  surface  veins.  Indeed,  the  great  bulk  of  the  blood 
from  the  hand  is  returned  by  the  superficial  veins  on 
the  dorsum  of  the  fingers  and  hand. 

The  lymphatics  of  the  palm  are,  moreover,  scant  and 
very  minnte,  whereas  on  the  dorsum  they  are  large  and 
profusely  distributed.  The  ulnar  border  of  the  palmar 
part  of  the  hand  is  much  used  in  pressure  and  in 
"  hammering  "  movements,  and  it  is  significant  that  this 
surface  is  well  protected  by  soft  parts,  and  presents  a 
singular  absence  of  large  nerves,  that,  if  present,  would 
be  liable  to  sustain  damage  from  such  movements. 

The  form  of  the  nail  varies  somewhat  in  individuals, 
and,  according  to  certain  authors,  there  are  special 
types  of  nail  to  be  met  with  in  some  constitutional 
diseases.  Thus  are  described  the  tubercular,  the 
rachitic,  the  arthritic  nail.  By  the  Hippocratic  hand 
is  meant  a  hand  the  tips  of  the  fingers  of  which  are 
clubbed  and  the  nails  of  which  are  much  curved.  This 
condition  would  appear  to  be  clue  to  impeded  circulation, 
to  retardation  in  the  return  of  venous  blood,  and  perhaps 


chap,  xv.]  The    Wrist  and  Hand.  261 

also  to  imperfect  oxygenation  of  that  blood.  It  is  most 
often  met  with  in  congenital  heart  disease,  in  phthisis, 
empyema,  chronic  lung  affections,  and  certain  thoracic 
aneurisms.  There  are  several  forms  of  inflammation 
affecting  the  matrix  of  the  nail  and  the  soft  parts 
immediately  around  it  (onychia,  paronychia).  Such 
inflammations  lead  to  great  deformity  of  the  structure 
itself.  When  a  nail  is  thrown  off  by  suppuration  or 
violence  a  new  nail  is  produced,  provided  any  of  the 
deeper  epithelial  cells  are  left.  During  convalescence 
from  certain  illnesses  (e.g.,  scarlet  fever),  a  transverse 
groove  will  appear  across  all  the  nails.  This  groove 
indicates  the  portion  of  nail  formed  during  the  illness, 
and  by  watching  its  movement  the  rate  of  growth  of 
the  nail  can  be  estimated.  The  nail  grows  at  the  average 
rate  of  ^nd  of  an  inch  per  week.  It  may  be  noted 
that  each  digital  nerve  gives  a  special  branch  of  large 
size  to  the  pulp  beneath  the  nail,  and  this  explains  the 
intense  pain  felt  when  a  foreign  body  is  thrust  under 
the  nail. 

The  fasciae. — Beneath  the  skin  of  the  palm  is  the 
dense  palmar  fascia.  This  fascia  gives  almost  as  much 
strength  to  the  hand  as  would  so  much  bone,  while 
its  unyielding  character,  its  comparative  freedom  from 
vessels  and  nerves,  render  it  well  suited  to  withstand 
the  effects  of  pressure.  The  fascia  gives  slips  to  each 
finger  ;  each  slip  sends  fibres  to  join  the  digital  sheaths 
of  the  tendons,  the  skin,  and  the  superficial  transverse 
ligament.  In  the  disease  known  as  Dupuytren's  con- 
traction, the  palmar  fascia,  and  especially  its  digital 
slips,  becomes  contracted.  One  or  more  or  all  of  tl  e 
fingers  may  be  involved  in  the  contraction.  The  first 
phalanx  is  drawn  or  flexed  towards  the  palm,  and  later 
the  second  phalanx  becomes  bent  also.  The  skin  is 
drawn  in  towards  the  fascia,  since  the  two  structures 
are  normally  connected  with  one  another.  Experiment 
shows  that  by  dragging  upon  the  fascia  the  first  phalanx 
can  be  readily  bent,  and  also,  hut  with  less  ease,  the 
second  phalanx.  The  middle  part  of  the  palmar  fascia, 
represents  the  tendon  of  the palmaris  longus  in  the  hand. 


262 


Surgical'  Applied  Anatomy.     [Chap.  xv. 


The  structures  of  the  palm  are  divided  into  three 
spaces  by  the  fasciae  (Fig.  35).  Thus  the  muscles  of 
the  thenar  and  hypothenar  eminences  are  both  enclosed 
in  a  thin  fascia  proper  to  each.  The  two  spaces  formed 
by  these  membranes  are  enclosed  in  all  directions,  and 
are  capable,  though  only  in  a  feeble  way,  of  limiting 
suppuration  when  it  commences  in  them.  Between 
these  two  spaces  is  a  third  space,  which  is  roofed  in  by 


Fig.  35.— Horizontal  Section  of  the  Hand  through  the  middle  of  the 
Thenar  and  Hypothenar  Eminences  (Tillaux). 

a,  Metacarpal  bone  ;  6,  first  dorsal  interosseous  ;  r,  palmaris  brevis;  e7,  abductor 
min.  digiti ;  e,  flexor  brevis  min.  dig. ;  /,  opponens  min.  dig. ;  g.  flexor  brevis 
poll.;  /!,  abductor  poll.;  i,  opponeus  poll.;  j,  adductor  poll.;  k,  flexor  long, 
pol. ;  I,  dorsal  interossei ;  m,  palmar  interossei ;  n,  flexor  sublimis ;  o,  flexor 
profundus ;  p,  super  fie.  volse ;  q,  median  nerve,  and  (on  inner  side)  ulnar  artery 
and  nerve;  r,  deep  palmar  arcb  ;  l,  palmar  fascia;  2,  outer  septum;  3,  inner 
septum  ;  4,  deep  fascia  of  palm. 


the  palmar  fascia.  \  This  cavity  is  closed  in  at  the  sides, 
but  is  open  above  and  below.  Above  there  is  a  free 
opening  beneath  the  annular  ligament  and  along  the 
flexor  tendons  into  the  fore-arm,  while  below  there  are 
the  seven  passages  provided  for  by  the  division  of  the 
palmar  fascia.  Of  these  seven  passages,  four,  situate 
at  the  roots  of  the  several  fingers,  give  passage  to  the 
flexor  tendons,  while  the  remaining  three  correspond 
to  the  webs  between  the  fingers,  and  give  passage  to 
the   lumbricales   and   the   digital   vessels   and    nerves. 


Chap,  xv.]  The   Wrist  and  Hand.  263 

When  pus,  therefore,  forms  on  the  palm,  beneath  the 
palmar  fascia,  it  cannot  come  forward  through  that 
dense  membrane,  but  escapes  rather  along  the  fingers 
or  makes  its  way  up  into  the  fore-arm.  So  rigid  is  the 
resistance  offered  by  the  palmar  fascia,  that  pent-up 
pus  will  make  its  way  through  the  interosseous  spaces 
and  appear  on  the  dorsum  of  the  hand,  rather  than 
come  through  the  coverings  of  the  palm.  The  passage 
of  pus,  however,  towards  the  dorsum  is  resisted  by  a 
layer  of  fascia  that  lies  deeply  beneath  the  flexor  tendons, 
and  covers  in  the  interossei  muscles,  the  bones,  and 
the  deep  palmar  arch.  This  fascia  joins  on  either  side 
the  fascia?  enclosing  the  thenar  and  hypothenar  "  spaces  " 
(Fig.  35). 

In  opening  a  palmar  abscess,  when  it  points  above 
the  wrist,  the  incision  should  be  in  the  long  axis  of 
the  fore-arm,  should  be  above  the  annular  ligament, 
and  is  most  conveniently  made  a  little  to  the  ulnar 
side  of  the  palmaris  longus,  for  a  cut  in  this  position 
would  escape  both  the  ulnar  and  radial  arteries  and 
also  the  median  nerve. 

The  tendons  about  the  wrist  are  bound  down  and 
held  in  place  by  the  annular  ligaments.  So  dense 
is  the  anterior  ligament,  that  even  in  extensive  abscess 
of  the  palm  reaching  into  the  fore-arm,  and  in  severe 
distension  of  the  synovial  sheaths  beneath  the  ligament, 
it  remains  firm,  and  will  not  yield.  The  lower  border 
of  the  posterior  annular  ligament  corresponds  to  the 
upper  edge  of  the  anterior  band,  and  these  structures 
together  act  the  part  of  the  leather  bracelet  that  the 
labourer  sometimes  wears  around  his  wrist,  and  that, 
in  fact,  takes  the  function  of  an  additional  annular 
ligament. 

The  fibrous  sheaths  for  the  flexor  tendons 
extend  from  the  metacarpophalangeal  joints  to  the 
upper  ends  of  the  third  phalanges.  The  pulp  of  the 
third  phalanx,  therefore,  rests  practically  upon  the 
periosteum.  Opposite  the  finger  joints  the  sheaths 
are  lax  and  thin,  and  spaces  may  occair  between  the 
decussating  fibres  of  the  sheaths,  through  which  the 


264 


Surgical  Applied  Anatomy.     [Chap.  xv. 


synovial  membrane  lining  the  sheath  may  protrude. 
It  is,  I  believe,  through  this  less  protected  part  of  the 
sheath  that  suppuration  without  often  finds  its  way 
into  the  interior  of  the  sheath.  The  sheaths  in  the  rest 
of  their  course  are  dense  and  rigid,  and  when  cut  across 
remain,  in  virtue  of  this  rigidity,  wide  open  (Fig.  36). 
Thus,  after  the  division  of  the  sheath,  as  in  amputation, 
an  open  channel  is  left  leading  into  the  palm  of  the  hand, 
and  offering  the  greatest  facility  for  the  spread  of  pus 
into  that  part.  It  is  this  rigidly  open  fibrous  sheath 
that  probably  may  explain  the  frequency  of  suppuration 
in  the  palm  after  amputation  of  a  part 
of  a  finger,  and  I  am  decidedly  of  opinion 
that  some  steps  should  be  taken  to 
protect  or  shut  off  this  channel  in  any 
case  where  the  sheath  has  been  accident- 
ally or  intentionally  divided. 

The  tendons  accurately  fill  the  fibrous 
sheaths.  A  gangliform  growth  on  the 
tendon  as  it  enters  the  sheath,  or  a 
constriction  of  the  sheath  with  an  in- 
equality in  the  tendon,  gives  rise  to  the 
condition  known  as  "  snap  "  finger.  Such 
a  digit  cannot  be  extended  by  will,  but 
when  pushed  a  little  way  "  springs  back 
with  a  snap  like  the  blade  of  a  pocket 
knife  "  (Abbe).  "  Congenital  contraction  " 
of  the  little  finger  is  very  common 
in  a  slight,  degree.  In  marked  cases,  the  proximal 
phalanx  is  hyper-extended  and  the  middle  flexed.  Lock- 
wood  found  in  such  a  case  that  the  condition  was  due 
to  a  contraction  in  the  fibrous  sheath  in  front  of  the 
joint.  Contracted  finger  following  whitlow  is  due  to 
an  adhesion  of  the  tendons  to  their  sheath.  Paralytic 
contraction  of  the  flexor  muscles  also  brings  about 
permanent  contracture  of  the  fingers. 

Synovial  sacs  and  sheathso  —  There  are 
two  synovial  sacs  beneath  the  annular  ligament  for 
the  flexor  tendons,  one  for  the  flexor  iongus  pollicis, 
the  other  for  the  flexor  sublimis  and  profundus  tendons. 


c 

Fig.  36.  —  Hori- 
zontal Section 
through  middle 
of  Second  Phal- 
anx (Tillaux). 

a,  Flexor  tendon  ; 
b,  fibrous  sheath 
of  tendon  ;  c,  ex- 
tensor tendoi  ; 
d.  digital  artery 
and  nerve. 


chap,  xv.]  The   Wrist  and  Hand.  265 

The  former  extends  up  into  the  fore-arm  for  about 
\\  inches  above  the  annular  ligament,  and  follows  its 
tendon  to  its  insertion  in  the  last  phalanx  of  the  thumb. 
The  latter  rises  about  \\  inches  above  the  annular 
band,  and  ends  in  diverticula  for  the  four  fingers.  The 
process  for  the  little  finger  usually  extends  to  the  insertion 
of  the  flexor  profundus  tendon  in  the  last  phalanx. 
The  remaining  three  diverticula  end  about  the  middle 
of  the  corresponding  metacarpal  bones.  The  synovial 
sheaths  for  the  digital  part  of  the  tendons  to  the  index, 
middle,  and  ring  fingers  end  above  about  the  neck  of  the 
metacarpal  bones,  and  are  thus  separated  by  about 
\  to  \  an  inch  from  the  great  synovial  sac  beneath 
the  annular  ligament.  Thus  there  is  an  open  channel 
from  the  ends  of  the  thumb  and  little  finger  to  a  point  in 
the  fore-arm  some  1^  inches  above  the  annular  ligament. 
The  arrangement  explains  the  well-known  surgical 
fact  that  abscesses  of  the  thumb  and  little  finger  are 
apt  to  be  followed  by  abscesses  in  the  fore-arm,  while 
such  a  complication  is  not  usual  after  suppuration  in 
the  remaining  fingers.  The  synovial  sac  for  the  flexor 
tendons  is  narrowed  as  it  passes  beneath  the  annular 
ligament,  and  thus  it  happens  that  when  distended 
with  fluid  or  with  pus,  it  presents  an  hour-glass  outline, 
the  waist  of  the  hour-glass  corresponding  to  the  ligament. 
The  two  synovial  sacs  beneath  the  ligament  sometimes 
communicate  with  one  another. 

In  one  form  of  whitlow,  that  form  where  the  pus 
occupies  the  synovial  sheaths  of  the  tendons  on  the 
fingers  (thecal  abscess),  the  suppuration  can  often  be 
seen  to  end  abruptly  where  the  sheath  ends,  when  the 
index,  middle,  or  ring  finger  is  involved,  viz.,  opposite 
the  neck  of  the  corresponding  metacarpal  bones.  In 
another  form  of  whitlow  (the  abscess  in  the  pulp  at 
the  end  of  the  finger)  the  periosteum  of  the  third  phalanx 
is  readily  attacked,  there  being  no  intervening  tendon 
sheath  over  that  bone.  In  this  affection  the  bone 
often  necroses  and  conies  away,  but  it  is  significant  to 
note  that  it  is  very  seldom  that  the  whole  of  the  phalanx 
perishes.     The  upper  part,  or  base,  of  the  bone  usually 


266  Surgical  Applied  Anatomy.     [Chap.  xv. 

remains  sound,  and  is  probably  preserved  by  the  in- 
sertion of  the  flexor  profundus  tendon.  It  is  also 
interesting  to  bear  in  mind  that  the  base  of  the  bone 
is  an  epiphysis  that  does  not  unite  to  the  shaft  until 
the  eighteenth  or  twentieth  year. 

The  tendons  do  not  lie  free  within  the  sac,  but  are 
bound  to  it  by  folds  of  synovial  membrane  in  much 
the  same  way  as  the  bowel  is  bound  to  the  abdominal 
parietes  by  its  mesentery.  These  folds  may  be  ruptured 
in  severe  sprains,  when  the  nutrient  vessels  for  the 
tendon,  which  are  contained  in  them,  may  be  torn. 
Rupture  is  followed  by  effusion  into  the  sac.  These 
folds  are  almost  absent  within  the  digital  sheaths,  the 
slight  ligamenta  longa  and  brevia,  near  the  insertion 
of  the  tendons,  being  the  sole  representatives.  Synovial 
sacs  are  lined  by  a  squamous  epithelium,  and  have  ex- 
tremely free  communication  with  the  lymphatic  vessels 
of  the  part.  Hence  the  free  absorption  of  infective 
matter  from  such  cavities. 

Beneath  the  posterior  annular  ligament  there  are 
six  synovial  sheaths  for  tendons,  corresponding  to  the 
six  canals  formed  by  that  ligament.  The  sheath  most 
frequently  inflamed  is  that  for  the  extensores  ossi  meta- 
carpi  and  brevis  pollicis.  It  runs  from  a  point  about 
f  of  an  inch  above  the  radial  styloid  process  to  the  first 
carpo-metacarpal  joint.  The  other  sheaths  reach  above 
to  the  upper  border  of  the  annular  ligament,  that  for 
the  two  radial  extensors,  however,  beginning  about 
^  an  inch  above  the  ligament.  The  sheaths  for  the 
extensor  communis  and  the  extensor  minimi  digiti 
extend  below  to  the  middle  of  the  metacarpus.  That 
for  the  extensor  indicis  barely  reaches  the  metacarpus. 
The  other  sheaths  follow  the  tendons  to  their  insertions. 
The  synovial  lining  and  folds  of  these  sheaths  are  injured 
in  Colles'  fracture  of  the  radius.  The  tendons  become 
adherent  to  their  sheaths  and  fixed  unless  this  be  pre- 
vented by  passive  movements  of  the  tendons. 

Blood-vessels  and  lymphatics. — The  hand 
is  very  well  supplied  with  blood,  and  indeed  the  finger 
pulp  is  one  of  the  most  vascular  parts  in  the  body. 


Chap,  xv  ]  The    Wrist  and  Hand.  267 

Cases  are  recorded  where  the  tip  of  the  finger  has  been 
accidentally  cut  off,  and  has  grown  again  to  the  limb 
on  being  immediately  re-applied.  The  position  of  the 
palmar  arches  has  been  pointed  out.  "Wounds  of  these 
arches,  and  indeed  of  most  of  the  arteries  of  the  palm 
and  wrist,  are  serious,  on  account  of  the  difficulty  of 
reaching  the  bleeding  point  without  seriously  damaging 
important  structures,  and  on  account  of  the  free  anas- 
tomoses that  exist  between  the  vessels  of  the  part. 
The  deep  palmar  arch  may  be  wounded  by  a  penetrating 
wound  from  the  dorsum,  and  indeed  Delorme  has 
pointed  out  that  this  arch  may  be  ligatured  from  the 
dorsum  after  a  preliminary  resection  of  the  upper  part 
of  the  third  metacarpal  bone.  It  is  well  known  that 
haemorrhage  from  either  of  the  palmar  arches  cannot  be 
checked  by  ligature  of  the  radial  or  ulnar  artery  alone, 
on  account  of  the  connection  of  the  arches  with  those 
vessels  ;  and  it  is  also  known  that  simultaneous  ligation 
of  the  two  vessels  may  have  no  better  effect,  owing  to 
the  anastomoses  between  the  palmar  arches  and  the 
interosseous  vessels.  The  anastomosis  is  carried  on  by 
means  of  the  carpal  arches.  The  anterior  carpal  arch 
communicates  with  the  anterior  interosseous  artery 
above,  and  with  the  deep  palmar  arch,  by  the  recurrent 
vessels  below.  The  posterior  carpal  arch  communicates 
with  the  two  interosseous  vessels  above,  and  with  the 
deep  palmar  arch  below,  by  means  of  the  perforating 
branches  from  the  latter  vessel.  The  anastomosis 
between  the  two  palmar  arches  is  well  known,  and  is 
freely  established  both  by  the  main  vessels  themselves 
and  by  the  communion  that  exists  between  the  digital 
arteries  from  the  superficial  arch  and  the  palmar  inter- 
osseous branches  from  the  deeper  vessels.  In  bleeding 
from  the  palm,  the  simultaneous  ligature  of  the  radial 
and  ulnar  arteries  may  also  entirely  fail  in  those  cases 
where  the  arches  are  freely  joined,  or  are  more  or  less 
replaced  by  large  and  abnormal  interosseous  vessels, 
or  by  a  large  "  median  "  artery.  When  either  the  radial 
or  the  ulnar  part  of  the  arches  is  defective,  the  lack  is 
usually  supplied  by  the  other  vessel ;    and  it  is  well  to 


268  Surgical  Applied  Anatomy.     [Chap. xv. 

note  that  the  deficiency  is  most  common  in  the  super- 
ficial or  ulnar  arch.  Pressure  applied  to  the  palm  to 
arrest  bleeding  is  apt  to  cause  gangrene,  owing  to  the 
rigidity  of  the  parts  and  the  ease  with  which  considerable 
pressure  can  be  applied. 

The  radial  artery,  as  it  curves  round  the  back  of 
the  hand  to  reach  the  deeper  part  of  the  palm,  is  in 
close  contact  with  the  carpo-metacarpal  joint  of  the 
thumb.  This  fact  must  be  borne  in  mind  in  amputation 
of  the  entire  thumb,  and  also  in  resection  of  the  first 
metacarpal  bone.  The  superficialis  volse,  if  large,  may 
bleed  seriously.  It  adheres  to  the  surface  of  the  annular 
ligament,  and  may  therefore  be  difficult  to  pick  up 
when  wounded. 

From  the  larger  size  and  great  number  of  the 
lymphatics  about  the  fingers  and  on  the  dorsum  of  the 
hand,  it  follows  that  lymphangitis  is  more  common 
after  wounds  of  those  parts  than  it  is  after  wounds 
of  the  palm. 

The  bones  and  joints. — The  inferior  radio- 
ulnar joint  is  supported  by  the  powerful  triangular 
fibre-cartilage,  which  forms  the  strongest  and  most 
important  of  all  the  ligamentous  connections  between 
the  two  bones.  The  synovial  sheath  of  the  extensor 
minimi  digiti  sometimes  communicates  with  this  joint, 
and  may  therefore  be  involved  when  that  articulation 
is  diseased. 

The  strength  of  the  wrist  joint  depends  not  so  much 
upon  its  mechanical  outline  or  its  ligaments  as  upon 
the  numerous  strong  tendons  that  surround  it,  and 
that  are  so  closely  bound  down  to  the  bones  about  the 
articulation.  Its  strength  depends  also  upon  its  prox- 
imity to  the  numerous  bones  and  joints  of  the  hand, 
whereby  all  movements  and  shocks  are  distributed 
between  several  articulations.  Moreover,  in  the  case 
of  the  wrist  the  long  lever  does  not  exist  on  the  distal 
side  of  the  joint.  The  movements  of  the  wrist  are 
greatly  supplemented  by  those  of  the  mid-carpal  joint. 
The  anterior  ligament  of  the  wrist  is  the  strongest 
ligament  of  the  joint,  while  the  posterior  is  the  weakest. 


Chap,  xv.]  The   Wrist  and  Hand.  269 

The  former  structure  limits  extension,  and  the  latter 
flexion  ;  and  in  connection  with  this  arrangement  it  is 
interesting  to  note  that  injury  from  forced  extension 
is  more  common  than  from  forced  flexion.  Thus, 
when  a  man  falls  upon  the  hand,  he  more  usually  falls 
upon  the  palm  (forced  extension)  than  upon  the  dorsum 
(forced  flexion).  Owing  to  the  thinness  of  the  posterior 
ligament,  together  with  the  more  superficial  position 
of  the  hinder  part  of  the  joint,  it  follows  that  the  effusion 
in  wrist-joint  disease  is  first  noticed  at  the  back  of  the 
hand.  As  the  tendons  on  the  front  and  at  the  back  of 
the  wrist  fairly  balance  one  another,  the  hand  in  wrist 
joint  disease  shows  little  tendency  to  be  displaced,  but 
is  fixed  rather  in  the  mid-position  between  flexion  and 
extension.  It  can  be  understood  that  in  this  disease 
the  neighbouring  synovial  sheaths  are  readily  involved. 

In  connection  "with  this  joint  it  may  be  noted  that 
the  middle  finger  is,  from  its  great  length,  the  one  most 
exposed  to  injury  and  to  shocks  received  by  the  fingers. 
Its  metacarpal  bone  is  directly  received  by  the  strongest 
carpal  bone,  the  os  magnum,  and  the  latter  bone  is 
brought  by  means  of  the  semi-lunar  into  connection  with 
the  widest  and  strongest  part  of  the  radius. 

But  little  movement  is  allowed  in  the  metacarpo- 
carpal  joints  of  the  first  three  fingers,  but  in  the  like 
joints  of  the  thumb  and  little  finger  movements  are 
free,  and  their  preservation  is  of  great  importance  to 
the  general  usefulness  of  the  hand.  The  glenoid  liga- 
ments in  front  of  the  three  finger  joints  are  firmly 
attached  to  the  distal  bone,  and  but  loosely  to  the 
proximal.  Thus  it  happens  that  in  dislocation  of  the 
distal  bone  backwards,  the  glenoid  ligament  is  carried 
with  it,  and  offers  a  great  obstacle  to  reduction.  In 
flexing  the  second  and  third  finger  joints  alone,  it  will 
be  seen  that  the  first  phalanx  is  steadied  by  the  extensor 
tendon  as  a  preliminary,  measure,  and  in  paralysis  of 
the  extensors  flexion  of  these  two  joints  alone  is  not 
possible. 

Very  few  persons  have  the  power  of  flexing  the 
lust  finger  joint  without  at  the  same  time  bending  the 


270  Surgical  Applied  Anatomy.     [Chap.  XV. 

articulation  above  it ;  but  in  certain  inflammatory 
affections  about  the  last  phalanges  the  terminal  joint 
is  sometimes  seen  to  be  fixed  in  a  flexed  posture  while 
the  other  finger  joints  are  straight.  In  the  condition 
known  as  "  mallet "  finger  the  distal  phalanx  is  fixed 
in  a  flexed  position.  The  condition  is  due  to  a  partial 
or  complete  rupture  of  the  extensor  tendon  of  the 
finger,  commonly  the  result  of  a  blow  over  the  terminal 
knuckles. 

Colles'  fracture.- — This  name  is  given  to  a 
transverse  fracture  through  the  lower  end  of  the  radius, 
from  \  to  1  inch  above  the  wrist  joint.  It  is 
associated  with  a  certain  definite  deformity,  and  is 
always  the  result  of  indirect  violence,  a  fall  upon  the 
outstretched  hand.  There  are  good  reasons  why  the 
bone  should  break  in  this  situation.  The  lower  end  of 
the  radius  is  very  cancellous,  while  the  shaft  contains 
a  good  deal  of  compact  bone.  At  about  J  of  an  inch 
from  the  articular  surface  these  two  parts  of  the  bone 
meet,  and  their  very  unequal  density  greatly  tends 
to  localise  the  fracture  in  this  situation.  As  to  the 
mechanism  of  this  lesion,  many  different  opinions  are 
still  held,  and  a  vast  deal  has  been  written  on  the  subject. 
I  subjoin  Professor  Chiene's  account  of  this  lesion, 
because  it  may  be  taken  as  representing  with  admirable 
clearness  the  views  most  generally  accepted  at  the 
present  time  as  to  the  nature  of  this  injury.  Into  the 
discussion  itself  I  do  not  propose  to  enter.  The  deformity 
in  Colles'  fracture  is  entirely  due  to  the  displacement 
of  the  lower  fragment.  "  The  displacement  is  a  triple  one : 
(a)  backwards,  as  regards  the  antero-posterior  diameter 
of  the  fore-arm ;  (6)  rotation  backwards  of  the  carpal 
surface  on  the  transverse  diameter  of  the  fore-arm ; 
(c)  rotation  through  the  arc  of  a  circle,  the  centre  of 
which  is  situated  at  the  ulnar  attachment  of  the  tri- 
angular ligament,  the  radius  of  the  circle  being  a  line 
from  the  ulnar  attachment  of  the  triangular  ligament 
to  the  tip  of  the  styloid  process  of  the  radius,  (a)  When 
a  person  in  falling  puts  out  his  hand  to  save  himself, 
at  the  moment  the  hand  reaches  the  ground  the  force 


Chap,  xv.]  The   Wrist  and  Hand.  27 1 

is  received  principally  by  the  ball  of  the  thumb,  and 
passes  into  the  carpus,  and  thence  into  the  lower  end 
of  the  radius.  If,  at  the  moment  of  impact,  the  angle 
between  the  axis  of  the  fore-arm  and  the  ground  is  less 
than  60°,  the  line  representing  the  direction  of  the 
force  passes  upwards  in  front  of  the  axis  of  the  fore-arm  ; 
the  whole  shock  is  therefore  borne  by  the  lower  end 
of  the  radius,  which  is  broken  off,  and,  the  force  being 
continued,  the  lower  fragment  is  driven  backwards. 
When  at  the  moment  of  impact  the  angle  is  greater 
than  60°,  the  line  of  the  force,  instead  of  passing  in 
front  of  the  axis  of  the  arm,  passes  up  the  arm,  and 
the  usual  result  is  either  a  severe  sprain  of  the  wrist 
or  a  dislocation  of  the  bones  of  the  fore-arm  backwards 
at  the  elbow  joint.  (6)  The  carpal  surface  of  the  radius 
slopes  forwards,  and  therefore  the  posterior  edge  of 
the  bone  receives  the  greater  part  of  the  shock  ;  there 
is,  as  a  result,  rotation  of  the  lower  fragment  backwards 
on  the  transverse  diameter  of  the  fore-arm.  (c)  The 
carpal  surface  of  the  radius  slopes  downwards  and 
outwards  to  the  radial  edge  of  the  arm ;  therefore 
the  radial  edge  of  the  bone  receives  the  principal  part 
of  the  shock  through  the  ball  of  the  thumb.  As  a 
result,  this  edge  of  the  lower  fragment  is  displaced 
upwards  to  a  greater  extent  than  the  ulnar  edge  of 
the  fragment,  which  remains  firmly  attached  to  the 
ulna  by  the  triangular  ligament."  This  rotation  also 
depends  upon  the  integrity  of  the  inferior  radio-ulnar 
ligament  in  a  typical  Colles'  fracture.  These  ligaments 
hold  on  to  the  ulnar  part  of  the  lower  fragment,  and 
prevent  its  being  displaced  to  so  great  an  extent  as 
is  the  radial  part  of  the  fragment.  By  means  of  this 
rotatory  displacement,  the  tips  of  the  two  styloid  pro- 
cesses come  to  occupy  the  same  level,  or  the  radial  process 
may  even  mount  above  the  ulnar.  In  nearly  every 
case  there  is  some  penetration  of  the  fragments,  the 
compact  tissue  on  the  dorsal  aspect  of  the  upper  fragment 
being  driven  (by  a  continuance  of  the  force  that  broke 
the  bone)  into  the  cancellous  tissue  on  the  palmar 
aspect  of  the  lower  fragment.     It  is  only  in  very  rare 


272  Surgical  Applied  Anatomy.     [Chap. xv. 

instances  that  the  fragments  are  so  separated  as  to 
ride  the  one  over  the  other.  In  such  cases  the  radio- 
ulnar ligaments  are  probably  ruptured,  and  the  wrist 
ceases  to  present  the  typical  deformity  of  a  Colles' 
fracture.  That  the  deformity  in  Colles'  fracture  is 
due  to  the  nature  and  direction  of  the  force  is  indirectly 
proved  by  an  isolated  case  or  so,  where  the  patient 
fell  upon  the  back  of  the  hand,  with  the  result  that 
the  radius  was  broken  in  the  usual  position  of  a  Colles1 
fracture,  but  the  lower  fragment  was  carried  forwards 
instead  of  backwards.  According  to  R.  W.  Smith 
and  others,  the  peculiar  deformity  is  produced  by  mus- 
cular action,  principally  by  the  supinator  longus,  the 
extensors  of  the  thumb,  and  the  radial  extensors. 
Lecomte  and  many  French  writers  assert  that  the 
fracture  is  due  to  a  tearing  (arrachement)  of  the  bone 
by  strain  upon  the  ligaments  of  the  wrist.  Thus  they 
assert  that  in  forcible  extension  of  the  hand  the  carpal 
condyle  is  thrust  against  the  anterior  wrist  ligaments  ; 
these  are  intensely  stretched,  and  tear  off  the  lower 
end  of  the  radius,  fracturing  it  through  what  is  ac- 
knowledged to  be  the  weakest  part  of  the  bone.  It  is 
true  that  in  young  subjects  the  lower  epiphysis  of  the 
radius  can  be  separated  in  the  cadaver  by  very  forcible 
flexion  or  extension  of  the  wrist  (B.  Anger).  This 
epiphysis  is  often  separated  by  accidental  violence. 
It  joins  the  shaft  about  the  twentieth  year.  Its  junction 
with  the  shaft  is  represented  by  a  nearly  horizontal 
line,  and  the  epiphysis  includes  the  facet  for  the  ulna 
and  the  insertion  of  the  supinator  longus.  Fractures 
of  the  lower  end  of  the  radius,  due  to  direct  violence, 
are  usually  associated  with  but  trifling  displacement. 

There  is  no  special  anatomical  interest  attaching 
to  fractures  of  the  carpus,  metacarpus,  or  phalanges. 

Dislocations. —  (l)  At  the  ivrist  joint. — So 
strong  is  this  articulation,  for  the  reasons  above  given 
(page  268),  that  carpo-radial  luxations  are  extremely 
rare.  For  the  same  reasons,  when  they  do  occur  they 
are  usually  complicated,  and  are  associated  with  tearing 
of  the  skin,  or  rupture  of  tendons,  01^  fractures  of  the 


Chap,  xv.]  The   Wrist  and  Hand.  273 

adjacent  bones.  The  luxations  of  the  carpus  may  be 
either  backwards  or  forwards,  the  latter  being  extremely 
rare.  They  would  appear  to  be  produced  with  equal 
ease  by  a  fall  upon  either  the  front  or  the  back  of  the 
hand.  Bransby  Cooper  gives  the  case  of  a  lad  who 
fell  upon  the  outstretched  palms  of  both  his  hands  : 
both  wrists  were  dislocated,  one  backwards,  the  other 
forwards. 

There  are  five  articular  synovial  cavities  connected 
with  the  carpus.  They  occur  in  the  following 
situations :  (a)  Between  the  carpus  and  fore-arm 
bones ;  it  may  communicate  with  the  lower  radio- 
ulnar cavity  through  the  triangular  nbro-cartilage  ; 
(b)  between  the  unciform  and  the  fourth  and  fifth 
metacarpals  ;  (c)  between  the  metacarpal  of  the  thumb 
and  trapezium  ;  (d)  between  all  the  carpal  bones  and 
extending  to  the  carpo-metacarpal  joints  of  the  second 
and  third  digits;  (e)  between  the  pisiform  and 
cuneiform  bones.  Hernial  protrusions  and  gangliform 
growths  from  these  synovial  membranes  are  frequently 
seen  on  the  dorsum  of  the  carpus. 

(2)  Some  dislocations  about  the  hand  (os  magnum). 
— In  forcible  flexion  of  the  hand,  the  os  magnum 
naturally  glides  backwards  and  projects  upon  the 
dorsum.  In  very  extreme  flexion  (as  in  falls  upon  the 
knuckles  and  dorsum  of  the  metacarpus),  this  movement 
of  the  bone  backwards  may  be  such  as  to  lead  to  its 
partial  dislocation,  the  luxation  being  associated  with 
some  rupture  of  ligaments.  In  one  recorded  case 
this  luxation  was  produced  by  muscular  force.  The 
patient,  a  lady,  while  in  labour,  "  seized  violently  the 
edge  of  her  mattress,  and  squeezed  it  forcibly."  Some- 
thing was  felt  to  give  way  in  the  hand,  and  the  head 
of  the  os  magnum  was  found  to  be  dislocated  backwards. 

Dislocations  at  the  metacarpophalangeal  joint  of 
the  thumb. — In  this  luxation  the  phalanx  is  usually 
displaced  backwards,  and  the  lesion  is  of  interest  on 
account  of  the  great  difficulty  often  experienced  in 
reducing  the,  bone.  Many  anatomical  reasons  have 
been  given  to  explain   this  difficulty,   which  are  well 


274  Surgical  Applied  Anatomy.     [Chap.  xv. 

summarised  by  Hamilton  in  the  following  passage : 
"  Hey  believes  the  resistance  to  be  in  the  lateral  liga- 
ments, between  which  the  lower  end  of  the  metacarpal 
bone  escapes  and  becomes  imprisoned.  Ballingall, 
Malgaigne,  Erichsen,  and  Vidal  think  the  metacarpal 
bone  is  locked  between  the  two  heads  of  the  flexor  brevis, 
or,  rather,  between  the  opposing  sets  of  muscles  which 
centre  in  the  sesamoid  bones,  as  a  button  is  fastened 
into  a  button-hole.  Pailloux  and  others  affirm  that 
the  anterior  ligament,  being  torn  from  one  of  its  attach- 
ments, falls  between  the  joint  surfaces,  and  interposes 
an  effectual  obstacle  to  reduction.  Dupuytren  ascribes 
the  difficulty  to  the  altered  relations  of  the  lateral 
ligaments,  ...  to  the  spasm  of  the  muscles,  and 
to  the  shortness  of  the  member,  in  consequence  of  which 
the  force  of  extension  has  to  be  applied  very  near  to  the 
seat  of  the  dislocation.  Lisfranc  found  in  an  ancient 
luxation  the  tendon  of  the  long  flexor  so  displaced 
inwards,  and  entangled  behind  the  extremity  of  the 
bone,  as  to  prevent  reduction."  Mr.  Jonathan 
Hutchinson,  junr..,  has  recently  investigated  some 
cases  and  found  that  reduction  is  prevented  by  the 
fibro-cartilaginous  plate.  The  plate  is  firmly  attached 
to  the  phalanx  and  is  dislocated  with  it.  When  sub- 
cutaneously  divided  on  the  extensor  aspect  of  the  thumb, 
the  dislocation  may  be  reduced  with  ease. 

Avulsion  of  one  or  more  fingers  may  be  effected 
by  severe  violence.  In  such  cases  the  finger  torn  off 
usually  takes  with  it  some  or  all  of  its  tendons.  These 
tendons  are  practically  drawn  out  of  the  fore-arm, 
and  may  be  of  considerable  length.  Billroth  figures  a 
case  where  the  middle  finger  was  torn  out,  taking  with 
it  the  two  flexor  and  extensor  tendons  in  their  entire 
length.  When  one  tendon  only  is  torn  away  with  the 
finger,  it  is  "usually  that  of  the  flexor  profundus. 

Amputation  at  the  wrist  joint  by  the  cir- 
cular method.  (See  the  author's  "  Operative  Surgery.") 
In  the  dorsal  wound  would  be  cut  the  following  ten- 
dons :  the  extensores  loiigus,  indicis,  communis,  minimi 
digiti,  and  ulnaris,   the  radial   nerve,   and  the   dorsal 


Chap,  xv.]  Tub   Wrist  and  Hand.  275 

branch  of  the  ulnar  nerve.  The  two  radial  extensors 
will  be  cut  short  in  the  radial  angle  of  the  wound,  as 
will  also  be  the  extensores  ossis  and  brevis.  The  radial 
artery  will  be  divided  close  to  the  radius.  In  the  palmar 
wound  would  be  found  the  ulnar  artery,  the  superficialis 
vola3,  the  ulnar  and  median  nerves,  the  opponens,  flexor 
brevis,  and  abductor  pollicis  in  part,  the  flexor  brevis, 
opponens,  and  abductor  minimi  digiti  in  part  (the  bulk 
of  the  opponens  being  left  behind  on  the  hand),  and 
the  tendons  of  the  flexor  sublimis  and  flexor  carpi  radialis. 
The  tendons  of  the  flexor  profundus  and  flexor  longus 
pollicis  are  usually  cut  short  close  to  the  bones. 

Amputation  of  the  thumb  at  the  carpo-meta- 
carpal  joint  by  flaps.  In  the  palmar  flap  would  be 
cut  the  abductor,  the  short  and  long  flexor,  the  op- 
ponens, and  adductor  pollicis.  The  extensores  ossis 
and  brevis  would  be  cut  short  in  the  posterior  angle 
of  the  flap.  The  extensor  longus  and  a  considerable 
portion  of  the  abductor  indicis  would  be  found  in  the 
dorsal  flap.  The  vessels  divided  would  be  the  two 
dorsal  arteries  of  the  thumb  and  the  princeps  pollicis. 
There  is  great  danger,  in  this  operation,  of  wounding 
the  radialis  indicis  and  the  radial  artery  itself  where  it 
begins  to  dip  into  the  palm. 

Nerve  supply  of  the  upper  limb. — The  symp- 
toms which  follow  a  lesion  to  the  nerves  of  the  upper 
limb  depend  on  the  point  injured.  If  the  fifth  spinal 
nerve  be  crushed  between  its  origin  in  the  spinal  cord 
and  its  exit  from  the  intervertebral  foramen,  either 
from  fracture  or  caries  of  the  cervical  vertebra?,  the  in- 
jury is  followed  by  paralysis,  partial  or  complete,  of  the 
deltoid,  biceps,  brachialis  anticus,  and  supinator  longus, 
while  a  strip  of  skin  on  the  outer  side  of  the  limb  from 
the  deltoid  to  the  styloid  process  of  the  radius  is  insensi- 
tive to  touch  or  paiti  (Fig.  3$).  Injury  to  the  .  ord  ju-t 
above  the  origin  of  the  eighth  cervical  vertebra  will  leave 
the  skin  of  the  ulnar  half  of  the  arm  anaesthetic,  while 
the  muscles  of  the  fingers,  hand,  and  wrist,  and  some  of 
those  at  the  elbow  and  shoulder,  will  lie  paralysed.  The 
fibres  for  the  innervation  of  the  various  groups  of  arm 


276  Sc/R  GICA  L    A  PPL  I  ED    A  NA  TO  MY.       [Chap.  XV. 

muscles  pass  out  in  quite  an  orderly  manner  by  the  fifth 
cervical  to  the  first  dorsal  nerve  from  corresponding 
segments  of  the  cord.  Those  for  the  abductors  of  the 
shoulder  pass  out  by  the  fifth  ;  for  the  adductors  by 
the  sixth  and  seventh  ;  for  the  flexors  of  the  elbow 
by  the  fifth  and  sixth ;  for  the  extensors  by  the 
seventh  and  eighth  ;  for  the  extensors  of  the  wrist 
and  fingers  by  the  sixth  and  seventh  ;  and  those  for 
the  flexors  by  the  eighth  and  first  dorsal.  It  is  important 
to  remember  that  a  cervical  spinal  nerve  makes  its  exit 
from  the  canal  opposite  the  origin  of  the  next  spinal 
nerve. 

The  following  is  Dr.  Herringham's  account  of  the 
usual  spinal  origin  of  the  fibres  in  the  nerves  of  the 
upper  limb,  and  of  the  usual  supply  of  the  chief  muscles. 
(The  figures  indicate  the  fifth,  sixth,  seventh,  and  eighth 
cervical  nerves,  and  the  first  dorsal  nerve.) 

Nerves. — Nerve  of  Bell,  5,  6,  7  ;  suprascapular,  5 
or  5,  6  ;  external  cutaneous,  5,  6,  7  ;  internal  cutaneous, 
1  or  8,  1  ;  nerve  of  Wrisberg,  1  ;  circumflex,  5,  6  ; 
median,  6,  7,  8,  1  ;  ulnar,  8,  1  ;  musculo-spiral,  6,  7,  8, 
or  5,  6,  7,  8. 

Muscles. — 3,  4,  5,  lev.  anguli  scap. ;  5,  rhomboids ; 
5  or  5,  6,  biceps,  brachialis  ant.,  supra-  and  infra- 
spinatus, teres  minor  ;  5,  6,  deltoid,  subscapularis  ;  6, 
teres  major,  pronator  teres,  flexor  carpi  rad.,  supin. 
longus  and  brevis,  superficial  thenar  muscles  ;  5,  6,  7, 
serratus  magnus  ;  6  or  7,  extensores  carpi  rad.  ;  7, 
coraco-brachialis,  latiss.  dorsi,  extensors  at  back  of 
fore-arm,  outer  head  of  triceps  ;  7,  8,  inner  head  of 
triceps  ;  7,  8,  1,  flexor  sublimis,  flexores  profund.,  carpi 
uln.,  long,  poll.,  pronator  quad.  ;  8,  long  head  of  triceps, 
hypothenar  muscles,  interossei,  deep  thenar  muscles. 

In  the  cutaneous  nerve  supply  of  the  fingers,  it  must 
be  remembered  that  on  the  palmar  aspect  the  thumb, 
the  two  outer  fingers,  and  the  radial  side  of  the  ring 
finger  are  supplied  by  the  median,  the  remaining 
one  and  a  half  fingers  by  the  ulnar  (Fig.  37).  On  the 
dorsal  aspect  the  thumb  is  supplied  by  the  radial,  the 
index  and  middle  fingers  are  supplied  (as  far  as  the  base 


277 


■   i      •  • 
5\\    /  \ 


\  7  i 


•      \8] 


9  i    10 


Fig.  37.— Cutaneous  Nerve  Supply  of  Upper  Limb. 

.interior  aspect :  1,   Cervical   plexus;  2,  circumflex  ;  3,  cxt.  cut.  otmusc.  spiral  ; 

4,  ext.  cutaneous  ;  5,  median  ;  6,  ulnar  j  7,  int.  cutaneous  ;  8,  n.  of  WfiBberg. 
Posterior  aspect :  1,  Cervical  plexus;  2,  circumflex;  3,  int.  cut.  of  muse,  spiral  ; 

Mntercosto-numeral  :  5,  n.  of  wrieberg;  6,  int.  cutaneous;  7, ext. cut.  of 

muse,  spiral ;  8.  exr.  cutaneous;  9,  ulnar  ;  10.  radial. 


278  Surgical  Applied  Anatomy.     [Chap.  xv. 

of  the  second  phalanx)  by  the  radial,  and  over  the  second 
and  third  phalanges  by  the  median.  The  little  ringer 
and  the  ulnar  side  of  the  ring  finger  are  supplied  by  the 
ulnar.  The  radial  side  of  the  ring  ringer,  as  far  as  the  base 
of  the  second  phalanx,  is  supplied  by  the  radial,  and  the 
rest  of  this  side  of  the  digit  by  the  median  (Fig.  37). 
The  cleft  between  the  middle  and  ring  fingers  is  occa- 
sionally supplied  by  the  ulnar,  or  partly  by  the  ulnar 
and  partly  by  the  radial.  The  roots  and  spinal  segments 
to  which  these  nerves  belong  may  be  ascertained  from 
Fig.  38.  The  roots  are  distributed  in  order  of  origin, 
the  fifth  cervical  beginning  on  the  radial  or  outer  side 
of  the  shoulder  and  the  second  dorsal,  or  sometimes  the 
third,  ending  on  the  ulnar  or  inner  aspect  of  the  upper 
arm.  The  hand  is  mainly  supplied  by  the  seventh.  The 
neighbouring  spinal  nerves,  as  is  also  the  case  with 
ordinary  terminal  branches,  overlap  widely  in  their 
distribution.  The  area  of  ansesthesia  is  much  less  than 
the  area  of  anatomical  distribution.  The  pain  referred 
along  the  ulnar  half  of  the  arm  in  cases  of  angina 
pectoris  and  aneurism  of  the  aorta  is  due  to  the  common 
origin  of  the  cardiac  and  aortic  sympathetic  nerves, 
and  those  for  the  ulnar  segment  of  the  arm  from  the 
first  dorsal  segment  of  the  spinal  cord  (Head). 

Injuries  to  the  main  nerves  of  the  upper 
limb. — The  entire  brachial  plexus  has  been  ruptured, 
leading  to  complete  paralysis  of  the  upper  limb.  In 
these  cases  it  would  appear  that  the  nerves  are  torn 
away  from  their  attachments  to  the  cord  rather  than 
broken  across  at  some  distance  from  it.  In  several 
instances  the  biceps  muscle  has  retained  some  of  its 
functions,  while  the  whole  of  the  other  muscles  have 
been  paralysed,  a  circumstance  perhaps  explained  by 
the  high  origin  of  the  bicipital  nerve  from  the  spinal 
cord. 

Paralysis  of  the  musculo~spiral  nerve. — 
When  complete,  the  hand  is  flexed  and  hangs  flaccid 
("  drop  wrist "),  and  neither  the  wrist  nor  the  fingers 
can  be  extended.  The  latter  are  bent  and  cover  the 
thumb,    which    is    also    flexed    and    adducted.     When 


TIN 


--D.III. 


s  --D.II. 


O  U 


Fig.  38.— Showing  the  Sensory  Distribution  of  the  Spinal  Nerves  in  the 

Upper  Limb. 

The  dotted  line*  indicate  approximately  the  area  of  each  nerve.  No  attempt 
is  made  to  show  the  extent  to  which  the  root  areas  overlap.  (For  the 
nerves  aupplying  cacti  an  a  ate  Fig.  37.) 


280  Surgical  Applied  Anatomy.     [Chap.  xv. 

attempts  are  made  to  extend  the  fingers,  the  interossei 
and  mmbricales  alone  act,  producing  extension  of  the 
last  two  phalanges  and  flexion  of  the  first.  Supination 
is  lost,  especially  if  the  elbow  be  extended  so  as  to  exclude 
the  action  of  the  biceps  muscle.  Extension  at  the  elbow 
is  lost,  and  sensibility  is  disturbed  over  the  skin  supplied 
by  the  nerve  (Erb). 

Paralysis  of  the  median  nerve. — Flexion  of 
the  second  phalanx  is  impossible  in  every  finger,  as 
is  also  a  like  movement  of  the  last  joint  of  the  index 
and  middle  fingers.  Partial  flexion  of  the  third  phal- 
anges of  the  two  inner  digits  is  possible,  the  inner  part 
of  the  flexor  profundus  being  supplied  by  the  ulnar 
nerve.  Flexion  of  the  first  phalanx  with  extension 
of  the  second  and  third  can  still  be  performed  in  all 
the  fingers  by  the  interossei.  The  thumb  is  extended 
and  adducted,  and  can  neither  be  flexed  nor  opposed. 
Bending  of  the  wrist  is  only  possible  when  the  hand 
is  forcibly  adducted  by  means  of  the  flexor  carpi  ulnaris, 
which  is  not  paralysed.  Pronation  is  lost.  Sensation 
is  disturbed  over  the  skin  supplied  by  the  nerve  (Erb). 

Paralysis  of  the  ulnar  nerve. — Ulnar  flexion 
and  adduction  of  the  hand  are  limited.  Complete 
flexion  of  the  two  inner  fingers  is  impossible.  The 
little  finger  can  scarcely  be  moved  at  all.  The  action 
of  the  interossei  and  two  inner  lumbricales  is  lost.  The 
patient  is  unable  to  adduct  the  thumb,  and  sensibility 
is  impaired  over  the  cutaneous  area  supplied  by  the 
nerve  (Erb). 

After  complete  division  of  any  one  of  the  three 
great  nerves  of  the  upper  limb,  the  loss  of  sensation 
in  the  cutaneous  parts  supplied  by  that  nerve  is  often 
quite  slight.  This  is  accounted  for  by  the  interlacings 
that  occur  between  the  principal  nerves  of  the  arm,  so 
that  when  a  given  trunk  is  injured  the  sensory  im- 
pressions are  returned  by  another  route.  Thus  are 
explained  those  cases  where  the  median  has  been  sutured 
after  accidental  division,  with  the  effect  that  within  a 
few  hours  sensation  has  returned  to  the  cutaneous 
parts  supplied  by  the  nerve.     Such  return  of  sensation 


chap,  xv.]  The   Wrist  and  Hand.  281 

is  probably  due  to  the  supplementary  action  of  the  inter- 
lacing nerve  fibres  bound  up  with  other  trunks,  and  not 
to  the  "  immediate  union  of  a  divided  nerve,"  as  was  at 
one  time  announced. 

Epiphyses  ol"  the  upper  limb, — The  epiphyses 
about  the  elbow  join  the  shafts  of  their  respective  bones 
at  17  years  (except  the  tip  of  the  internal  condyle,  which 
joins  at  18).  The  epiphyses  at  the  shoulder  and  wrist 
extremities  of  the  bones  join  at  20.  The  nutrient  canals 
of  the  three  bones  run  towards  the  elbow.  The  nutrient 
artery  of  the  humerus  comes  from  the  brachial  or  inferior 
profunda,  those  of  the  radius  and  ulna  from  the  anterior 
interosseous. 

The  nerve  supplying  the  humerus  is  the  musculo- 
cutaneous. The  radius  and  ulna  are  supplied  by  the 
anterior  interosseous  of  the  median. 


2»2 


£art  $V. 

The  Abdomen  and  Pelvis. 


CHAPTER    XVI. 

THE   ABDOMEN. 

The  abdominal  parietes. — Surface  anatomy. 
— The  degree  of  prominence  of  the  abdomen  varies 
greatly.  The  protuberance  of  the  belly  in  young 
children  is  mainly  due  to  the  relatively  large  size  of 
the  liver,  which  occupies  a  considerable  part  of  the 
cavity  in  early  life.  It  also  depends  upon  the  small 
size  of  the  pelvis,  which  is  not  only  unable  to  accommo- 
date any  abdominal  structure  (strictly  so  called),  but 
can  scarcely  provide  room  for  the  pelvic  organs  them- 
selves. Thus  in  infancy  the  bladder  and  a  great  part 
of  the  rectum  are  virtually  abdominal  viscera.  After 
long-continued  distension,  as,  for  example,  after  preg- 
nancy, ascites,  etc.,  the  abdomen  usually  remains  unduly 
prominent  and  pendulous. 

In  examples  of  prolapse  of  the  mesentery  the  upper 
part  of  the  abdomen  becomes  sunken  in  and  the  lower 
part  unduly  prominent.     (See  page  320.) 

In  cases  of  great  emaciation  it  becomes  much  sunken, 
and  its  anterior  wall  appears  to  have  collapsed.  This 
change  is  most  conspicuous  about  the  upper  part  of  the 
region.  Here  the  anterior  parietes  immediately  below 
the  line  of  the  costal  cartilages,  instead  of  being  in  the 
same  plane  with  the  anterior  thoracic  wall,  may  so  sink 
in  as  to  be  almost  at  right  angles  with  that  wall  on  the 
one  hand,  and  with  the  lower  part  of  the  abdominal 
parietes  on  the  other.  In  such  cases  the  abdominal 
walls  just  below  the  thoracic  line  may  appear  to  be 


chap.  xvi. j  The  Abdomen,  283 

almost  vertical  when  the  patient  is  in  the  recumbent 
posture.  This  change  of  surface  is  of  importance  in 
gastrostomy,  since  the  subjects  for  that  operation  are 
usually  much  emaciated,  and  the  incision  has  to  be 
made  close  below  the  costal  line. 

The  position  of  the  linea  alba  above  the  umbilicus 
is  indicated  by  a  slight  median  groove,  but  no  such 
indication  exists  below  the'  navel.  The  linea  semi- 
lunaris may  be  represented  by  a  slightly  curved  line 
drawn  from  about  the  tip  of  the  ninth  costal  cartilage 
to  the  pubic  spine.  In  the  adult  it  would  be  placed 
about  3  inches  from  the  navel.  Above  the  umbilicus 
the  line  is  indicated  on  the  surface  by  a  shallow  depression. 
The  outline  of  the  rectus  can  be  well  seen  when  the 
muscle  is  in  action.  It  presents  three  "  linea?  trans- 
versa?," one  usually  opposite  the  xiphoid  cartilage,  one 
opposite  the  umbilicus,  and  a  third  between  the  two. 
The  two  upper  of  these  lines  are  obvious  on  the  surface 
in  well-developed  subjects. 

The  site  of  the  umbilicus  varies  with  the  obesity  of 
the  individual  and  the  laxity  of  the  abdomen.  It  is 
always  below  the  centre  of  the  line  between  the  xiphoid 
cartilage  and  the  pubes.  In  the  adult  it  is  some  way 
above  the  centre  of  the  body,  as  measured  from  head 
to  foot,  while  in  the  foetus  at  birth  it  is  below  that  point. 
It  corresponds  in  front  to  the  disc  between  the  third 
and  fourth  lumbar  vertebra?,  and  behind  to  the  tip 
of  the  third  lumbar  spinous  process.  It  is  situated 
about  \  of  an  inch  to  1  inch  above  a  line  drawn  between 
the  highest  points  of  the  two  iliac  crests. 

The  anterior  superior  spine,  the  pubic  spine,  and 
Poupart's  ligament  are  all  conspicuous  and  important 
landmarks.  The  pubic  spine  is  nearly  in  the  same 
horizontal  line  with  the  upper  edge  of  the  great  tro- 
chanter. It  is  very  distinct  in  thin  subjects.  In  the 
obese  it  is  entirely  lost  beneath  the  pubic  fat.  In  such 
individuals,  however,  it  can  be  detected,  when  the 
subject  is  a  male,  by  invaginating  the  scrotum  so  as  to 
pass  the  finger  beneath  the  subcutaneous  fat.  In  the 
female  the  position  of  the  process  may  be  made  out  by 


284  Surgical  Applied  Anatomy.    [Chap.  xvi. 

adducting  the  thigh  and  thus  mating  prominent  the 
tendon  of  origin  of  the  adductor  longus  muscle.  This 
muscle  arises  from  the  body  of  the  pubes  immediately 
below  the  spine,  and  by  running  the  finger  along  the 
muscle  the  bony  prominence  may  be  reached.  If  the 
finger  be  placed  upon  the  pubic  spine  it  may  be  said 
that  a  hernia  descending  to  the  inner  side  of  the  ringer 
will  be  inguinal,  while  one  presenting  to  the  outer  side 
will  be  femoral.  In  the  erect  position  of  the  body  the 
anterior  superior  spine  is  a  little  above  the  level  of  the 
promontory  of  the  sacrum,  while  the  tip  of  the  xiphoid 
cartilage  corresponds  to  about  the  lower  part  of  the 
tenth  dorsal  vertebra. 

In  that  part  of  the  back  which  corresponds  to  the 
abdominal  region  the  erector  spinee  masses  are  distinct, 
and  in  any  but  fat  subjects  their  outer  edges  can  be 
well  defined.  Between  these  masses  is  the  spinal  furrow, 
which  ends  below  in  an  angle  formed  by  the  two  great 
gluteal  muscles.  Immediately  above  the  middle  of  the 
crest  of  the  ilium  is  Petit's  triangle,  or  the  gap  between 
the  external  oblique  and  latissimus  dorsi  muscles.  The 
fourth  lumbar  spine  is  about  on  a  level  with  the  highest 
part  of  the  iliac  crest.  In  counting  the  ribs  it  is  well 
to  commence  from  above,  since  the  last  rib  may  not 
project  beyond  the  outer  edge  of  the  erector  spinse, 
and  may  consequently  be  overlooked. 

The  aorta  bifurcates  opposite  the  middle  of  the  body 
of  the  fourth  lumbar  vertebra  just  to  the  left  of  the 
middle  line.  This  spot  corresponds  very  nearly  to  the 
highest  point  of  the  iliac  crest,  and  will  therefore  be 
situate  about  f  of  an  inch  below  and  to  the  left  of  the 
umbilicus.  A  line  drawn  on  either  side  from  the  point 
of  bifurcation  to  the  middle  of  Poupart's  ligament  will 
correspond  to  the  course  of  the  common  and  external 
iliac  arteries.  The  first  2  inches  of  this  line  would  cover 
the  common  iliac,  the  remainder  the  external. 

The  cceliac  axis  comes  off  opposite  the  lower  part 
of  the  twelfth  dorsal  vertebra,  at  a  spot  about  4  or  5 
inches  above  the  navel,  and  that  corresponds  behind 
to  the  twelfth  dorsal  spine.     The  superior  mesenteric 


Chap,  xvi.]  The  Abdomen.  285 

and  suprarenal  arteries  are  just  below  the  axis.  He 
renal  vessels  arise  about  \  an  inch  below  the  superior 
mesenteric,  opposite  a  spot  some  3^-  inches  above  the 
umbilicus,  and  on  a  level  behind  with  the  gap  between 
the  last  dorsal  and  first  lumbar  spines.  The  inferior 
mesenteric  artery  comes  off  from  the  aorta  about  1  inch 
above  the  umbilicus.  The  deep  epigastric  artery  follows 
a  line  drawn  from  the  middle  of  Pou part's  ligament 
to  the  umbilicus.  Along  the  same  line  may  sometimes 
be  seen  the  superficial  epigastric  vein. 

The  abdominal  "  rings  "  will  be  referred  to  in  the 
paragraph  on  hernia. 

Anterior    abdominal    parietes.  —  The    skin 
over  the  front  of  the  abdomen  is  loosely  attached  in  the 
region  of  the  groin.     This  condition  is  taken  advantage 
of  in  certain  operations,  e.g.,  Wood's  procedure  for  the 
radical  cure  of  hernia.     It  also  allows  of  the  incision 
for  herniotomy  in  the  inguinal  region  being  made  by 
transfixing  a  fold  of  the  skin  that  has  been  pinched  up 
over  the  external  ring.     The  skin  is  more  adherent  to 
the  deeper  parts  in  the  middle  line  than  elsewhere,  but 
not  so  adherent  as  to  hinder  the  spread  of  inflammation 
from  one  side  of  the  abdomen  to  the  other.     In  cases 
of   great   obesity   two   transverse   creases   form   across 
the   belly,   one   crossing  the   umbilicus   and   the   other 
passing  just  above  the  pubes.       In  the  former  of  the 
two   creases   the    navel   is   usually  hidden   from   sight. 
In  cases  of  anchylosed  hip-joints  transverse  creases  are 
often   noted   running  across   the   middle   of  the   belly. 
They  are  produced  by  the  freer  bending  of   the  spine 
that  is  usually  permitted   in   anchylosis,   some   of  the 
simpler     movements    of    the    hip    joint    being    trans- 
ferred to  the  column  when  the  articulation  is  rendered 
useless. 

After  the  skin  has  been  stretched,  from  any  gross 
distension  of  the  abdomen,  certain  silvery  streaks  appear 
in  the  integument  over  its  lower  part.  They  are  due 
to  an  atrophy  of  the  skin  produced  by  the  stretching, 
and  their  position  serves  to  indicate  the  parts  of 
the  parietes  upon  which  distending  forces  within  the 


286  Surgical  Applied  Anatomy.    [Chap.  xvi. 

abdomen  act  most  vigorously.     They  are  well  seen  after 
pregnancy,  ascites,  ovarian  tumours,  etc. 

Beneath  the  skin  is  the  superficial  fascia,  which 
over  the  lower  half  of  the  abdomen  can  be  readily  divided 
into  two  layers.  The  great  bulk  of  the  subcutaneous 
fat  of  this  region  is  lodged  in  the  more  superficial  of 
the  two  layers.  In  cases  of  great  obesity  the  accumu- 
lation of  fat  is  perhaps  more  marked  beneath  the  skin 
of  the  abdomen  than  it  is  elsewhere.  A  layer  of  fat 
6  inches  in  depth  has  been  found  in  this  region  in  cases 
of  great  corpulence.  The  superficial  vessels  and  nerves 
lie  for  the  most  part  between  the  two  layers  of  the  fascia, 
so  that  in  obese  subjects  incisions  may  be  made  over 
the  abdomen  to  the  depth  of  an  inch  or  so  without 
encountering  blood-vessels  of  any  magnitude. 

The  deep  layer  of  the  superficial  fascia  contains 
elastic  fibres,  and  corresponds  to  the  tunica  abdominalis 
or  "  abdominal  belt "  of  animals.  It  is  attached  to 
the  deeper  parts  along  the  middle  line  as  far  as  the 
symphysis,  and  to  the  fascia  lata  just  beyond  Poupart's 
ligament.  In  the  interval  between  the  symphysis  and 
the  pubic  spine  it  has  no  attachment,  but  passes  down 
into  the  scrotum  and  becomes  the  dartos  tissue. 
Extra vasated  urine  that  has  reached  the  scrotum  may 
mount  up  on  to  the  abdomen  through  this  interval, 
and  will  then  be  limited  by  the  deeper  layer  of  the  fascia. 
It  will  not  be  able  to  pass  down  into  the  thigh  on  account 
of  the  attachments  of  the  fascia,  nor,  for  a  like  reason, 
will  it  tend  to  pass  over  the  middle  line.  In  the  same 
way  emphysematous  collections  following  injuries  to 
the  chest,  when  beneath  the  deeper  layer  of  the  fascia, 
receive  a  check  at  the  groin,  and  lipomata  also  that 
grow  beneath  the  membrane  tend  to  be  limited  by 
the  middle  line  and  that  of  Poupart's  ligament. 

The  anterior  abdominal  parietes  vary  in  thickness 
in  different  subjects.  In  cases  of  great  emaciation  the 
outlines  of  some  of  the  viscera  may  be  readily  made 
out  or  even  seen  through  the  thinned  wall.  In  some 
cases  of  chronic  intestinal  obstruction  the  outlines 
of  the  distended  intestine  are  visible,  and  their  move- 


Chap,  xvi.]  The  Abdomex.  287 

ments  can  be  watched ;  in  instances  of  obstruction  of 
the  pylorus  the  movements  of  the  dilated  and  hyper- 
trophied  stomach  can  often  be  seen.  The  relative 
thickness  of  the  abdominal  wall  in  various  subjects 
depends  rather  upon  the  amount  of  the  subcutaneous 
fat  than  upon  the  thickness  of  the  muscles.  This  mus- 
cular boundary  affords  an  admirable  protection  to  the 
viscera  within.  By  contracting  the  abdominal  muscles 
the  front  of  the  belly  can  be  made  as  hard  as  a  board, 
and  in  acute  peritonitis  this  contraction  can  sometimes 
be  seen  to  produce  a  remarkable  degree  of  rigidity. 

A  blow  upon  the  abdomen  when  the  muscles  are 
firmly  contracted  will  probably  do  no  injury  to  the 
viscera  unless  violence  be  extreme.  The  rigid  muscular 
wall  acts  with  the  efficacy  of  a  dense  indiarubber  plate. 
It  may  be  bruised  or  torn,  but  it  will  itself  receive  the 
main  shock  of  the  contusion. 

The  probable  effect  on  the  contained  viscera  of  a 
blow  upon  the  abdomen  will  depend  upon  many  factors  ; 
but,  so  far  as  the  walls  themselves  are  concerned,  the 
effect  greatly  depends  upon  whether  the  blow  was 
anticipated  or  not,  and  upon  the  extent  of  the  padding 
of  fat  that  is  furnished  to  the  parietes.  If  the  blow 
be  anticipated  the  muscles  of  the  belly  will  be  instinctively 
contracted,  and  the  viscera  be  at  once  provided  with 
a  firm  but  elastic  shield.  Thus  the  abdominal  muscles 
have  been  found  bruised  and  torn  while  the  viscera  were 
intact,  and,  on  the  other  hand,  in  cases  probably  where 
the  muscles  were  inert  or  taken  unawares  a  viscus  has 
been  found  to  be  damaged  without  any  conspicuous 
lesion  in  the  belly  wall.  If  the  blow  be  anticipated 
also  the  body  will  probably  be  abruptly  bent  and  the 
viscera  be — as  it  were — removed  from  danger. 

Along  the  linea  alba  the  abdominal  wall  is  thin, 
dense,  and  free  from  visible  blood-vessels.  Hence  in 
most  operations  upon  the  abdominal  cavity  the  incision 
is  made  in  the  middle  line.  Along  the  outer  border  of 
the  rectus  muscle  {i.e.  about  and  just  beyond  the  linea 
semilunaris)  the  parietes  are  also  thin  and  lacking  in 
vessels,  and  consequently  that  situation  is  well  suited 


288  Surgical  Applied  Anatomy.    [Chap.  xvi. 

for  an  incision.  Except  in  some  operations  on  the 
kidney,  stomach,  or  gall  bladder,  incisions  are  seldom 
so  placed.  In  most  cases  it  is  a  question  of  either 
opening  the  abdomen  in  the  middle  line  or  in  one  of 
the  iliac  regions.  Below  the  navel  the  two  recti  muscles 
are  almost  in  contact,  and  here  the  linea  alba  can  scarcely 
be  said  to  exist.  Above  the  umbilicus  the  two  muscles 
tend  to  separate  a  little,  and  the  "  line  "  increases  greatly 
in  width.  In  pregnancy  and  in  other  forms  of  distended 
abdomen  the  median  interval  between  the  recti  may 
be  much  increased. 

The  structures  immediately  behind  the  linea  alba 
are,  from  above  downwards,  the  liver,  stomach,  and 
transverse  colon  above  the  umbilicus,  and  the  small 
intestines  and  bladder  (when  distended)  below  it.  There 
are  often  little  spaces  between  the  fibres  of  the  linea 
alba,  and  through  these  pellets  of  fat  from  the  sub- 
peritoneal tissue  may  grow.  If  of  fair  size  these  little 
masses  may  be  mistaken  for  irreducible  hernise.  Similar 
growths  of  fat  may  extend  through  the  inguinal  or 
femoral  openings,  and  constitute  the  so-called  "  fatty 
hernise." 

The  fibrous  ring  of  the  umbilicus  is  derived  from 
the  linea  alba.  To  this  ring  the  adjacent  structures, 
skin,  fasciae,  and  peritoneum,  are  all  closely  adherent. 
The  adhesion  is  such,  and  the  amount  of  tissue  between 
the  skin  and  peritoneum  is  so  scanty,  that  in  operating 
upon  an  umbilical  hernia  it  is  scarcely  possible  to  avoid 
opening  the  sac. 

The  umbilicus  represents  the  point  where  the  lateral 
abdominal  walls  finally  close.  At  the  sixth  week  the 
opening  is  funnel-shaped  and  contains  the  yolk  sac  and 
a  fold  of  the  bowel  to  which  it  is  attached.  This  con- 
dition may  persist  and  give  rise  to  a  congenital  hernia 
of  the  umbilicus.  In  the  foetus  three  vessels  enter  at 
the  navel,  and  immediately  separate  on  reaching  the 
abdominal  cavity,  the  vein  passing  directly  upwards 
and  the  arteries  obliquely  downwards.  Eunning  down 
from  the  umbilicus  in  the  middle  line  is  also  the  remains 
of  the  urachus.     In  the  foetus,  the  spot  where  the  three 


chap,  xvi.]  The  Abdomen  289 

vessels  part  company  is  about  the  centre  of  the  navel, 
and  it  thus  happens  that  in  a  congenital  umbilical 
hernia  the  gut  as  it  escapes  separates  the  three  vessels, 
which  become  to  some  extent  spread  over  it.  The 
congenital  hernia,  indeed,  works  its  way  in  among  the 
structures  of  the  cord  and  receives  its  main  covering 
from  them.  These  hernise  are  fortunately  rare,  for  in 
certain  instances  they  extend  some  way  into  the  cords, 
and  in  at  least  two  reported  cases  the  gut  was  cut  across 
by  the  accoucheur  in  dividing  the  cord  at  birth.*  As 
the  abdomen  increases  in  height  the  contraction  of  the 
two  obliterated  arteries  and  of  the  urachus  drags  upon 
the  cicatrix  and  pulls  it  backwards  and  downwards. 
Thus,  in  the  adult  umbilical  ring,  as  viewed  from  the 
inner  side,  the  cords  representing  not  only  the  obliterated 
arteries  and  the  urachus,  but  also  the  vein,  appear 
to  start  from  the  lower  border  of  the  cicatrix.  In  adult 
hernias,  indeed,  the  gut  escapes  above  both  the  obliterated 
arteries  and  the  vein.  The  upper  half  of  the  cicatrix 
is  thin  when  compared  to  the  lower  half,  and  is  supported 
also  by  less  firm  adhesions. 

In  some  cases  a  fistula  is  found  at  the  navel  that 
discharges  urine.  This  is  due  to  a  patent  urachus. 
The  urinary  bladder  is  formed  by  a  dilatation  of  the 
stalk  of  the  allantois.  The  part  below  this  dilatation 
becomes  the  first  part  of  the  urethra,  that  above  becomes 
the  urachus.  In  one  instance  of  patent  urachus  the 
abnormal  opening  was  1  inch  in  diameter.  The  patient, 
a  man  aged  40,  had  a  stone,  which  was  extracted  by 
passing  the  finger  into  the  bladder  through  the  opening 
at  the  umbilicus. 

Sometimes  a  fistula  discharging  fasces  is  met  with 
at  the  navel.  This  depends  upon  the  persistence  of  the 
vitello-intestinal  duct,  a  duct  that  at  one  time  connects 
the  rudimentary  intestine  with  the  yolk  sac,  and  that 
generally  disappears  without  leaving  any   trace.     The 

*  The  congenital  hernia  must  be  distinguished  from  the 
infantile  umbilical  hernia  so  commonly  met  with  after  separa- 
tion of  the  cord.  For  an  account  of  these  congenital  hernia?, 
see   paper  by  the  author  in  the  Lancet,  vol.  i.,   1881,   p.  323. 


290  Surg/cal  Applied  Anatomy.    [Chap. xvi. 

persistent  duct,  when  it  occurs,  is  known  as  Meckel's 
diverticulum,  and  springs  from  the  ileum  from  one 
to  four  feet  above  the  ileo-csecal  valve.  This  foetal 
relationship  also  explains  the  presence  of  a  fibrous  cord 
which  is  sometimes  seen  connecting  Meckel's  diverti- 
culum with  the  umbilicus.  It  may  cause  strangulation 
of  the  bowel. 

The  position  of  the  transverse  intersections  of  the 
rectus  muscle  should  be  borne  in  mind.  They 
adhere  to  the  anterior  layer  of  the  rectus  sheath,  but 
not  to  the  posterior.  They  are  able,  therefore,  in  some 
extent  to  limit  suppurative  collections  and  haemorrhages 
beneath  the  sheath  on  its  anterior  aspect.  This  muscle 
is  often  the  seat  of  one  form  of  "  phantom  tumour." 
These  tumours  are  mostly  met  with  in  the  hysterical 
and  hypochondriac,  and  when  associated  with  some 
vague  abdominal  symptoms  are  apt  to  mislead.  They 
are  due  to  a  partial  contraction  of  the  muscle,  usually 
to  a  part  between  two  intersections,  and  are  said  to  be 
more  common  in  the  upper  part  of  the  rectus.  When 
the  fibres  of  the  muscle  are  contracted  the  "tumour  " 
is  obvious,  hut  when  they  relax  it  disappears.  The 
phantom  tumour,  however,  is  not  always  a  matter 
of  little  moment.  It  may  be  associated  with  grave 
disease  within  the  abdomen,  and  be  clue  to  reflex  mus- 
cular contraction,  the  starting  point  of  such  reflex  act 
being  in  the  viscera. 

I  have,  for  example,  seen  a  conspicuous  phantom 
tumour  in  the  upper  part  of  the  right  rectus  associated 
with  cancer  of  the  stomach,  with  ulcer  of  the  duodenum, 
and  with  malignant  disease  of  the  peritoneum. 

Other  vanishing  tumours  depend  upon  distension 
of  the  intestines  by  flatus  or  by  faecal  matter.  In  great 
distension  of  the  abdomen  the  fibres  of  the  rectus  may 
be  much  stretched,  since  they  bear  the  brunt  of  the 
distending  force.  The  direction  of  the  fibres  also  renders 
them  liable  to  be  torn  in  the  opisthotonos,  or  extreme 
arching  of  the  back,  of  tetanus.  Portions  of  the  muscle 
have  also  been  ruptured  by  muscular  violence. 
I  In  women,  as  a  result  of  many  pregnancies,  the  recti 


Chap,  xvi.]  The  Abdomen.  291 

may  become  separated.     The  separation  is  usually  I  clew 
the  umbilicus,  and  the  condition  is  known  as  divarication 

of  the  recti. 

Luschka  quotes  a  case  in  which  the  separation  of  the 
muscles  was  so  great  that  the  interval  between  them 
took  in  almost  the  whole  of  the  anterior  wall  of  the 
abdomen.     The  recti  muscles  were  found  in  the  flanks. 

The  lateral  muscles  of  the  front  abdominal  wall 
are  separated  from  one  another  by  layers  of  loose  con- 
nective tissue.  These  extensive  layers  favour  the  spread 
of  interstitial  abscesses  of  the  abdominal  parietes.  Such 
abscesses  w  ill  be  guided  in  their  course  by  the  attachments 
of  the  muscles  between  which  they  spread,  and  will  be 
limited  by  the  semilunar  lines  in  front,  by  the  lower 
parts  of  the  ribs  and  their  cartilages  above,  by  Poupart's 
ligament  and  the  iliac  crest  below,  and  by  the  edge  of 
the  erector  spinse  behind.  The  same  remark  applies  to 
haemorrhagic  or  emphysematous  collections  between 
these  muscles. 

Between  the  abdominal  parietes  and  the  perito- 
neum is  a  layer  of  loose  connective  tissue,  the  sub- 
serous connective  tissue.  The  looseness  of  this 
layer  greatly  favours  the  spread  of  abscess,  to  the  pro- 
gress of  which  it  offers  little  resistance.  Such  an 
abscess  may  spread  from  the  viscera,  especially  from 
those  that  have  an  imperfect  peritoneal  covering,  as, 
for  example,  the  kidney,  the  vertical  parts  of  the  colon, 
etc.  The  laxity  of  this  tissue  has  been  of  service  in 
certain  surgical  procedures.  Thus  the  external  and 
common  iliac  arteries  can  be  reached  by  an  incision 
made  some  way  to  the  outer  side  of  the  vessels  and 
without  opening  the  peritoneum.  That  membrane 
having  been  exposed  in  the  lateral  wound,  the  artery 
is  reached  by  working  a  May  with  the  finger  through 
the  subperitoneal  tissue,  and  by  actually  stripping  the 
serous  membrane  from  its  attachments.  Ligature  of  the 
iliac  vessels  at  the  present  day  is  usually  effected  through 
a  direct  incision  which  opens  the  peritoneal  cavity.  The 
method  just  detailed  belongs  to  pre-antiseptic  days. 
The  laxity  of    the  subserous  laver  also  favours  lliat 


292  Surgical  Applied  Anatomy.    [Chap.  xvi. 

stretching  of  the  peritoneum  which  occurs  under 
certain  circumstances.  Sarcomata  are  not  unfrequently 
met  with  in  the  subserous  or  retroperitoneal  connective 
tissue,  and  when  so  placed  the  laxity  of  that  tissue  allows 
them  to  spread  readily,  especially  when  they  attack  the 
retroperitoneal  tissue  lining  the  posterior  walls  of  the 
abdominal  cavity. 

Wounds  of  the  abdomen  may  give  trouble  in 
their  treatment,  since,  when  inflicted,  they  may  open 
up  several  layers  of  fascia  and  so  lead  to  bagging  of 
pus  and  to  the  spread  of  suppuration  should  an  abscess 
follow  the  lesion.  When  the  more  muscular  parts 
are  divided  the  condition  of  the  layers  incised  is  such 
that  great  facilities  are  offered  for  the  embedding  of 
small  foreign  bodies,  such  as  pieces  of  glass,  etc.,  which, 
hidden  between  the  muscular  layers,  may  well  be  over- 
looked. Mr.  Pollock  records  a  case  where  the  metal 
part  of  a  steel  fork  with  two  prongs  was  overlooked 
and  allowed  to  remain  buried  in  the  abdominal  walls 
for  a  considerable  time. 

The  constant  respiratory  movements  of  the  belly 
walls  do  not  favour  that  rest  which  is  so  essential 
to  the  healing  of  wounds. 

In  penetrating  wounds  the  contraction  of  the  muscles 
may  encourage  the  protrusion  of  the  viscera,  especially 
when  the  incision  is  transverse  to  the  direction  of  the 
muscular  fibres.  In  reducing  small  portions  of  pro- 
truded viscera  it  is  quite  possible  to  push  them  into  one 
of  the  connective  tissue  spaces  between  the  muscles 
or  into  the  subserous  tissue  instead  of  into  the  peritoneal 
cavity.  In  applying  sutures  to  wounds  involving  the 
whole  thickness  of  the  parietes  it  is  necessary  that  the 
threads  should  include  the  peritoneum  so  that  early 
healing  of  that  membrane  may  be  brought  about. 
Without  such  precaution  a  gap  may  be  left  in  the  surface 
of  the  peritoneum  which  would  favour  the  formation 
of  a  hernia  in  the  site  of  the  old  wound. 

Blood-vessels. — The  only  arteries  of  any  magni- 
tude in  the  abdominal  walls  are  the  two  epigastric 
arteries,   some  branches  of  the  deep  circumflex  iliac, 


Chap,  xvi.]  The  Abdomen.  293 

the  last  two  intercostal  vessels,  the  epigastric  branch 
of  the  internal  mammary,  and  the  abdominal  divisions 
of  the  lumbar  arteries.  The  superficial  vessels  are 
of  small  size,  although  Verneuil  reports  a  case  of  fatal 
haemorrhage  from  the  superficial  epigastric  vessel. 

The  superficial  veins  on  the  front  of  the  abdomen 
are  numerous,  and  are  very  distinct  when  varicose. 
A  lateral  vein,  extending  from  the  axilla  to  the  groin, 
uniting  the  axillary  and  femoral  veins,  is  often  ren- 
dered in  this  way  very  prominent.  The  surface  abdom- 
inal veins  may  take  no  part  as  alternative  blood  channels 
in  cases  of  obstruction  of  the  inferior  vena  cava. 
Clinical  experience  shows  that  these  veins  may  lie  also 
enormously  varicose  in  instances  where  the  inferior 
cava  is  quite  patent.  In  one  case  under  my  care  there 
Avas  extensive  varicosity  of  the  surface  veins  from  the 
pectoral  region  to  the  groin  that  involved  one  side  of  the 
body  only.  It  has  been  shown,  moreover,  that  the  valves 
of  these  vessels  are  so  arranged  that  the  blood  in  the 
surface  veins  above  the  navel  goes  to  the  axilla,  while 
that  in  the  veins  of  the  subumbilical  region  runs  to  the 
groin. 

Schiff  has  shown  that  certain  small  veins  con- 
nect the  portal  vein  with  the  epigastric  veins  at  the 
umbilicus. 

As  regards  the  surface  lymphatics  of  the  front  of 
the  abdomen,  it  may  be  said  in  general  terms  that  those 
above  the  umbilicus  go  to  the  axillary  glands,  and  those 
belowr  to  the  glands  of  the  groin. 

IMerves. — The  abdominal  wall  is  supplied  by  the 
lowest  seven  dorsal  or  intercostal  nerves,  and  by  the 
first  lumbar  nerve.  These  nerves  run  obliquely  to 
the  long  axis  of  the  abdomen  downwards  and  inwards 
from  the  sides  to  the  middle  line  and  hence  are  damaged 
more  extensively  in  vertical  than  in  oblique  incisions. 
Their  direction  is  represented  by  a  continuation  of  the 
lines  of  the  ribs  :  they  are  placed  parallel  to  one  another 
and  at  fairly  equal  distances  apart.  It  is  important 
to  note  that  they  supply  not  only  the  abdominal  integu- 
ment, but  also  the  muscles  of  the  belly,  viz.,  the  rectus, 


294  Surgical  Applied  Anatomy,    pchap.  xvi. 

the  two  oblique  muscles,  and  the  transversalis.  The 
segments  of  the  spinal  cord  which  supply  the  skin  also 
innervate  the  underlying  muscles,  an  association  of 
great  importance  (Fig.  39).  If  a  cold  hand  be  suddenly 
placed  upon  the  belly  the  muscles  at  once  contract 
and  the  abdomen  is  instinctively  rendered  rigid.  The 
safety  of  the  viscera,  so  far  as  at  least  protection  from 
contusions  is  concerned,  depends  upon  the  readiness 
with  which  the  muscles  can  contract  at  the  first  indica- 
tion of  danger.  As  has  been  already  stated,  the  viscera 
have  a  very  efficient  protection  against  the  effects  of 
blows  when  the  belly  muscles  are  in  a  state  of  rigid 
contraction.  The  sensitive  skin  acts  the  part  of  a 
sentinel,  and  the  intimate  association  of  the  surface 
nerves  with  the  muscular  nerves  allows  the  warnings 
of  this  sentinel  to  be  readily  given  and  immediately 
acted  upon.  If  the  skin  and  the  muscles  were  supplied 
from  different  segments  a  longer  interval  would  elapse 
between  the  warning  to  the  skin  and  the  muscular 
contraction  than  occurs  when  those  two  parts  are  both 
supplied  by  the  same.  The  rigidity  of  the  muscles  in 
certain  painful  affections  of  the  skin  over  the  abdomen 
is  often  very  conspicuous.  I  might  instance  the  case 
of  a  man  with  a  burn  over  the  belly.  While  the  burn 
is  protected  by  the  dressings  the  abdominal  muscles 
are  lax  and  the  parietes  move  with  the  respiratory  act. 
The  moment  the  dressings  are  removed,  the  surface 
becoming  painful,  its  spinal  centre  becomes  excited  and 
the  muscles  at  once  contract  and  the  belly  becomes 
rigid.  It  will  be  noticed  that  six  of  the  abdominal 
nerves  supply  intercostal  muscles,  and  are  thus 
intimately  associated  with  the  movements  of  respiration. 
The  abdominal  muscles  are  of  course  concerned  in  the 
same  movements.  These  associations  are  illustrated 
when  cold  water  is  suddenly  dashed  upon  the  belly. 
The  subject  of  such  experiment  at  once  experiences 
a  violent  respiratory  movement  in  the  form  of  a  deep 
gasp.  When  the  abdominal  muscles  are  firmly  fixed 
the  lower  ribs  are  also  rigid,  and  respiration  is  limited 
to  the  higher  ribs  and  to  the  thorax  proper. 


Chap  XVI.] 


Thi'.  Abdomen. 


295 


There  are  other  practical  points  about  these  nerves. 
In  caries  of  the  spine,  and  in  certain  injuries  to  the 
column,  the  spinal   nerves  may  suffer  injury  as  they 


Fit 


39. — Showing  approximately  the  areas  of  skin  supplied  by  spina 
nerves  on  the  anterior  surface  of  the  trunk. 

The  areas  are  marked  on  the  right  side  by  dotted  lines,  and  the  number  ol  t  lie 

si>in;il  nerve  by  which  caeh  is  supplied,  is  indicated.    The  nerves  are  shown 
on  the  left  side. 


Issue  from  the  vertebral  canal.  This  injury  may  show 
itself  by  modified  sensation  in  the  parts  supplied  by 
such  nerves.  Thus  in  Pott">  disease  the  patient  often 
complains  of  a  sense  of  tightness  about  the  abdomen, 
as  if  a  cord  were  tied  around  it.     Tins  sense  of  con- 


296  Surgical  Applied  Anatomy.    [Chap. xvi. 

striction  depends  upon  an  impaired  sensation  in  the 
parts  supplied  by  a  certain  pair  of  nerves  ;  or,  if  the 
sense  of  constriction  be  wider  spread,  by  two  or  more 
pairs  of  nerves.  In  other  cases  a  sense  of  pain  may 
take  the  place  of  that  of  constriction.  It  would  hardly 
be  believed  that  spinal  disease  has  been  mistaken  for 
"  belly-ache."  But  many  such  cases  have  been  recorded. 
A  child  complains  of  pain  over  the  pit  of  the  stomach 
or  about  the  umbilicus,  and  this  feature  may  quite 
absorb  for  a  while  the  surgeon's  attention.  The  abdomen 
is  carefully  poulticed,  while  the  only  mischief  is  in  the 
vertebral  column.  Other  symptoms,  however,  develope, 
and  it  becomes  evident  that  the  pain  is  due  to  pressure 
upon  the  nerves  supplying  the  skin  over  the  epigastric 
or  umbilical  regions,  and  that  that  pressure  is  a  cir- 
cumstance in  the  course  of  spinal  bone  disease.  A 
case  came  under  my  notice  in  which  a  man  complained 
of  intense  and  abiding  pain  over  the  stomach.  The 
pain  was  made  worse  by  food  and  as  all  means  used 
failed  to  relieve  it,  the  abdomen  was  opened  by  an 
exploratory  incision.  Nothing  abnormal  was  discovered. 
A  little  later  it  became  evident  that  the  pain  was  clue 
to  a  malignant  tumour  situated  in  the  bodies  of  the 
dorsal  vertebrae.  There  had  never,  before  the  operation, 
been  any  suspicion  of  spinal  disease.  The  site  of  the 
painful  part  depends,  of  course,  upon  the  position  of 
the  spinal  ailment,  and  thus  the  cutaneous  symptoms 
may  serve  to  localise  the  caries  in  the  vertebrae.  Thus 
the  skin  over  the  "  pit  of  the  stomach  "  is  supplied  by 
the  sixth  and  seventh  dorsal  nerves  and  the  tenth  nerve 
is  nearly  in  a  line  with  the  umbilicus.  The  position  of 
the  areas  supplied  by  each  spinal  nerve  on  the  trunk 
is  shown  in  Fig.  39.  The  umbilicus  may  be  at  the 
upper  or  lower  border  of  the  area  of  the  tenth,  according 
to  the  individual.  A  spinal  root  may  be  cut  and  yet 
scarcely  a  trace  of  anaesthesia  result  owing  to  the 
overlapping  of  the  nerve  distributions. 

The  nerves  of  the  body  wall  have  still  more 
important  associations.  The  spinal  segments  with 
which  they  are  connected  are  also  in  communication 


Chap,  xvi.]  The  Abdomen.  297 

with  the  viscera  of  the  abdomen  and  thorax  through 
the  sympathetic  system.  Hence  diseased  conditions 
in  the  abdominal  viscera  give  rise  to  disturbances  in 
the  spinal  segments,  with  which  they  are  connected, 
and  the  brain,  being  accustomed  to  localise 
pain  only  along  the  spinal  nerves,  makes  a 
mistake  and  refers  the  pain  along  the  spinal  nerve  of 
the  segment  disturbed.  Not  only  is  pain  referred,  but 
the  skin  supplied  from  the  disturbed  spinal  segments" 
becomes  tender,  and  through  a  study  of  these,  Head  has 
been  able  to  localise  the  visceral  centres,  thus  affording 
the  surgeon  a  means  for  increased  accuracy  of  diagnosis. 
The  abdominal  viscera  are  supplied  from  the  sixth 
dorsal  to  the  first  lumbar  spinal  segments,  the  nerves 
passing  to  their  destinations  through  the  rami  com- 
municantes,  splanchnic  nerves  and  sympathetic  plexuses 
of  the  abdomen.  Xo  visceral  nerves  escape  by  the 
second,  third  or  fourth  lumbar  nerves,  hence  these 
an-  never  the  seats  of  visceral  referred  pains.  The 
pelvic  visceneare  supplied  from  the  fifth  lumbar  to  the 
third  or  sometimes  fourth  sacral  nerve  through  the 
nervi  errigentes. 

The  following  are  the  segments  with  which  each 
viscus  is  connected  (Head) : — Stomach,  G,  7,  8,  9  D.  ; 
intestine,  9,  10,11,  12  T).  ;  rectum,  2,  3,  t  S. ;  liver 
and  gall  bladder  7,  8,  9,  10  D.  ;  kidney  and  ureter,  10, 
11,  12  D.,  1  L.  ;  prostate,  1<),  11  I)., "5  L.,  1,  2,  3  S. ; 
epididymis,  11,  12,  1  ]).  ;  testis  and  ovary,  10  1).  ; 
appendages,  11,  12  D.,  1  L. ;  uterus,  10,  1 1,  12  D.,  1  L., 
3,  \  S. 

Pain  referred  to  districts  supplied  by  the  lower 
abdominal  nerves  in  connection  with  spinal  caries  may 
mislead  the  surgeon  from  the  real  seat  of  the  malady, 
and  may  arouse  a  suspicion  of  mischief  in  the  kidneys 
or  bladder. 

*  Head  regards  cacti  area  as  supplied  by  a  segment  of  the 
spinal  cord,  and  not  necessarily  by  one  spinal  nerve.  The  areas 
he  has  demarcated  on  the  trunk,  with  some  exceptions,  correspond, 
however,  very  closely  with  the  anatomical  distribution  of  spinal 
nerves. 


298  Surgical  Applied  Anatomy.   [Chap.  xvi. 

It  may  be  noted  that  some  of  these  nerve  disturbances, 
especially  the  sense  of  a  constricting  band,  are  common 
in  certain  affections  of  the  spinal  cord,  such  as  locomotor 
ataxia,  etc. 

This  nerve  relationship  is  illustrated  in  disease  in 
many  ways.  Thus,  in  acute  peritonitis  and  in  laceration 
of  certain  of  the  viscera  the  abdominal  muscles  become 
rigidly  contracted,  so  as  to  insure  as  complete  rest  as 
possible  to  the  injured  parts.  In  acute  peritonitis 
the  belly  is  very  hard,  the  respirations  are  purely  thoracic, 
and  so  entirely  do  the  cutaneous  portions  of  these  nerves 
enter  into  the  situation,  that  the  patient  is  often'unable  to 
tolerate  even  the  most  trifling  pressure  upon  his  abdomen. 

Congenital  deformities  of  the  abdomen.— 
In  the  foetus  the  intestinal  canal  is  cut  off  from  the 
yolk  sac  by  the  gradual  growth  of  the  ventral  plates 
and  their  ultimate  union  in  the  middle  line.  This 
union  occurs  latest  at  the  umbilicus,  and  when 
complete  the  abdominal  cavity  is  entirely  enclosed. 
In  some  cases  of  imperfect  development  the  anterior 
abdominal  wall  is  more  or  less  entirely  absent,  and 
the  viscera  are  either  entirely  uncovered  or  protected 
only  by  a  scanty  membrane.  This  condition  is  usually 
associated  with  other  deformities,  which  are  inconsistent 
with  any  but  very  brief  existence.  In  many  cases  the 
abdominal  walls  are  fairly  complete,  but  there  is  a  lack 
of  union  in  the  middle  line  about  the  umbilicus.  Thus 
result  the  various  forms  of  congenital  exomphalos, 
which  may  vary  in  severity  from  a  small  hernia  to  a 
protrusion  of  the  whole  of  the  more  movable  viscera. 
One  of  the  most  remarkable  deformities  is  that  known 
as  extroversion  of  the  bladder.  Here,  not  only  is  a  part 
of  the  belly  wall  absent,  but  also  a  part  of  the  genito- 
urinary apparatus.  In  complete  cases  there  is  an  absence 
of  the  umbilicus  and  of  the  anterior  abdominal  wall 
below  it.  There  is  no  symphysis  pubis,  an  absence 
of  the  anterior  wall  of  the  bladder,  of  the  principal  part 
of  the  penis,  and  the  whole  of  the  roof  of  the  urethra. 
The  scrotum,  also,  as  may  be  expected  from  a  reference 
to  the  development  of  that  part,  is  bifid. 


chap,  xvi.]  The  Abdomen.  299 

Hernia* — 1.  Inguinal  hernia. — In  this  form  of 
rupture    the    herniated    bowel    occupies    the    inguinal 

canal  for  the  whole  or  part  of  its  entire  length.  This 
canal  runs  obliquely  from  the  internal  to  the  external 
abdominal  ring,  and  is  about  ll  inches  in  length.  It 
represents  the  track  followed  by  the  testis  in  its  descent. 
Ij  is,  in  a  sense,  a  passage  right  through  the  abdominal 
walls,  and  is  occupied  by  the  spermatic  cord.  It  is 
not  a  free"  canal,  however,  in  the  same  sense  as  one  would 
>peak  of  an  open  tube,  but  is  rather  a  potential  one,  a 
tract  of  tissue  so  arranged  as  to  permit  of  a  body  being 
thrust  along  it.  It  is  a  breach  in  the  abdominal  wall, 
not  a  doorway  ;  a  breach  that  is  forcibly  opened  up  and 
widened  in  the  acquired  forms  of  hernia.  When  a  hernia 
occupies  the  inguinal  canal  it  is  covered  in  front  by  the 
integuments,  the  external  oblique  aponeurosis,  and  the 
lower  fibres  of  the  internal  oblique  and  transversalis 
muscles.  It  rests  behind  upon  the  transversalis  fascia, 
the  conjoined  tendon,  and  the  triangular  ligament-, 
over  it  arches  the  transverse  and  internal  oblique 
muscles,  while  below  it  is  the  angle  formed  by  the  union 
of  Poupart's  ligament  with  the  transversalis  fascia. 
The  herniated  bowel  is  contained  within  a  "  sac,"  which 
is  always  formed  of  peritoneum.  In  congenital  hernia 
the  sac  exists  already  formed  in  the  form  of  an  abnormally 
patent  "  processus  vaginalis."  In  acquired  hernia1  the 
sac  consists  of  that  part  of  the  parietal  peritoneum  which 
the  gut  pushes  before  it  in  its  descent. 

The  external  abdominal  ring  is  readily  felt  by  invag- 
inating  the  scrotum  with  the  point  of  the  finger,  and 
then  pissing  the  digit  up  in  front  of  the  cord.  If  the 
nail  be  kept  against  the  cord  the  pulp  of  the  finger  can 
readily  recognise  its  triangular  slit-like  opening.  Under 
ordinary  circumstances  in  adults  it  will  just  admit  the 
tip  of  the  little  finger.*     The  internal  ring  is  situate 

*  In  cases  of  congenital  or  acquired  absence  of  the  cord  the 
external  ring  may  be  almost  obliterated.  Paulet  quotes  from 
Malgaigne  the  case  of  an  old  man  wliose  testicle  had  been  removed 
in  infancy,  and  in  whom  the  external  ring  was  so  small  as  to  be 
scarcely  recognisable. 


300  Surgical  Applied  Anatomy.   [Chap.  xvi. 

about  |   an  inch  above  the  middle  of  Pouparts  liga- 
ment. 

There  are  two  principal  forms  of  inguinal  hernia, 
which  can  be  best  understood  by  a  view  of  the  anterior 
abdominal  parietes  from  within.     From  such  an  aspect 
it  will  be  seen  that  the  peritoneum  is  marked  by  three 
linear   ridges   that   run,    roughly   speaking,   from   the 
umbilicus  to  the  pelvic  brim.       One  of  these  ridges 
follows  the  middle  line  from  the  navel  to  the  symphysis 
and  represents  the  urachus ;    a  second,  that  may  be 
indicated  by  a  line  drawn  from  the  middle  of  Poupart's 
ligament  to  the  navel,  represents  the  deep  epigastric 
artery ;   while  between  these  two,  and  much  nearer  to 
the  epigastric  vessel  than  to  the  middle  line,  is  the  line 
formed    by    the    obliterated    hypogastric    artery.     By 
means  of  these  ridges  the  peritoneum  is  made  to  present 
three  fossae,  an  external  to  the  outer  side  of  the  epigastric 
artery,  an  internal  between  the  urachus  and  the  hypo- 
gastric artery,  and  a  middle  between  the  tract  of  the 
latter  vessel  and  the  epigastric  trunk.     The  internal 
ring  (so  called)  is  just  to  the  outer  side  of  the  epigastric 
artery,  and  the  site  of  the  summit  of  the  inguinal  canal 
is  indicated  by  a  depression  in  the  peritoneum.     When 
a  hernia  follows  the  inguinal  canal  throughout  its  entire 
length,    it    is    called    oblique,    indirect,    or    external  ; 
"  oblique  "  or  "  indirect "  from  its  taking  the  oblique 
direction  of  the  canal,   "  external "  from  the  position 
of  its  neck  with  reference  to  the  epigastric  vessel.     The 
coverings  of  such  a  hernia  would  be  the  same  as  those 
of  the  cord,  viz.,  the  skin,  the  superficial,  intercolumnar, 
cremasteric  and  infundibuliform  layers  of    fascia,  the 
subserous  tissue,  and  the  peritoneum.     When  the  hernia 
escapes  to  the  inner  side  of  the  deep  epigastric  artery, 
through  the  space  known  as  Hesselbach's  triangle,  it 
is  called  a  direct  or  internal  hernia,  for  reasons  that 
will  be  obvious.     There  may  be  two  forms  of  direct 
hernia.     In  one  form  the  gut  escapes  through  the  middle 
fossa  above  described,  in  the  other  through  the  inner 
fossa   between  the  hypogastric  artery  and  the  outer 
edge  of  the  rectus  muscle.     The  middle  fossa  is  nearly 


Chap,  xvr.]  The  Abdomen.  301 

opposite  to  the  summit  of  the  external  ring.  A  hernia 
escaping  through  that  fossa  would  enter  the  inguinal 
canal  some  little  way  below  the  point  of  entrance  of 
an  oblique  hernia,  and  would  have  the  same  coverings 
as  that  hernia,  with  the  exception  of  the  infundib ali- 
form fascia.  The  first  covering,  indeed,  that  it  would 
receive  from  the  canal  structures  would  be  the  cre- 
masteric fascia.  The  inner  fossa  corresponds,  so  far 
as  the  inguinal  canal  is  concerned,  with  the  external 
ring.  A  hernia  escaping  through  this  fossa  would  be 
resisted  by  the  conjoined  tendon  and  the  triangular 
ligament.  These  structures  are  either  stretched  over 
the  hernia  so  as  to  form  one  of  its  coverings,  or  the 
conjoined  tendon  is  perforated  by  the  hernia,  or  lastly 
the  gut  deviates  a  little  in  an  outward  direction  so  as 
to  avoid  the  tendon  and  appear  at  its  outer  side 
(Velpeau).  In  any  case  the  hernia  is  forced  almost 
directly  into  the  external  abdominal  ring.  The 
coverings  of  such  hernise  are  the  skin  and  superficial 
fascia,  the  intercolumnar  fascia,  the  triangular  liga- 
ment and  conjoined  tendon  (with  the  exceptions  above 
mentioned),  the  transversalis  fascia,  subserous  tissue, 
and  peritoneum. 

An  examination  of  the  abdominal  wall,  apart  from 
clinical  experience,  would  lead  one  to  suspect  that  the 
direct  hernia  would  be  more  common  than  the  indirect, 
since  the  parietes  are  certainly  less  resisting  opposite 
Hesselbach's  triangle  than  they  are  in  the  parts  imme- 
diately external  to  the  epigastric  artery.  Indeed,  just 
to  the  outer  side  of  the  conjoined  tendon  the  belly  wall 
is  remarkably  thin.  These  conditions,  however,  seem 
to  offer  less  facilities  for  the  escape  of  a  hernia  than 
does  the  inguinal  canal  itself.  The  funnel-shaped 
depression  in  the  peritoneum  at  the  summit  of  that 
canal  seems  to  offer  particular  inducements  for  rupture, 
and  there  are,  besides,  certain  congenital  detects  in  the 
vaginal  process  of  the  peritoneum  that  render  hernia 
almost  unavoidable  along  the  inguinal  canal. 

Direct  versus  indirect  inguinal  hernia.— 
The  indirect  hernia,  as  just  hinted,  may  be  congenital. 


302  Surgical  Applied  Anatomy.   [Chap.  xvi. 

the  direct  is  never  congenital.  In  the  congenital 
oblique  hernia  the  outline  of  the  inguinal  canal  and 
the  relations  of  the  various  parts  concerned  are  but 
little  disturbed,  and  the  differences  between  this  form 
of  rupture  and  the  direct  variety  are  conspicuous. 
The  acquired  oblique  hernia,  however,  does  not  present 
such  a  contrast  to  the  direct  form  as  may  be  expected. 
In  the  first-named  rupture,  from  constant  dragging 
upon  the  parts  the  internal  ring  becomes  more  or  less 
approximated  to  the  external  ring,  and  the  length  of 
the  canal  and  consequently  the  obliquity  of  the  hernia 
are  considerably  reduced.  Thus  the  axes  of  the  two 
forms  of  rupture  do  not  present  such  differences  as  to 
make  their  nature  at  once  obvious.  The  direct  hernia, 
however,  on  reduction,  will  pass  directly  back  into  the 
belly,  while  the  indirect  will,  even  in  old  cases,  take  a 
slight  but  appreciable  direction  outwards.  After  the 
reduction  of  the  direct  hernia,  the  edge  of  the  rectus 
muscle  may  be  readily  felt  to  the  inner  side  of  the  aper- 
ture, the  protrusion  being,  indeed,  at  the  semilunar 
line.  From  the  slight  inducement  offered  to  its  progress, 
and  from  its  insignificant  neck,  the  direct  hernia  is 
usually  small  and  globular,  while  for  opposite  reasons 
the  oblique  rupture  may  attain  large  size,  and  tends 
to  assume  a  pyriform  outline. 

Forms  of  oblique  hernia  depending  upon 
congenital  defects  in  the  "vaginal  process." 
The  descent  of  the  testis. — It  is  well  known  that  the 
testis  in  the  foetus  descends  from  the  region  of  the 
kidney  into  the  scrotum  by  making  a  way  through  the 
abdominal  wall  that  is  afterwards  known  as  the  in- 
guinal canal. 

Its  descent  is  preceded  by  the  passage  into  the  scrotum 
of  a  process  of  the  peritoneum,  the  vaginal  process. 
The  testicle  usually  enters  the  internal  ring  about  the 
seventh  month  of  foetal  life,  and  by  the  eighth  month  is 
in  the  scrotum.  The  testis  is  guided  to  its  final  resting 
place  by  the  gubernaculum,  a  band  of  muscular  fibres. 
This  band  is  attached  below  to  the  anterior  abdominal 
parietes,  to  the  pubes  near  the  root  of  the  perns,  to  the 


Chap,  xvi.]  The  Abdomen.  303 

bottom  of  the  scrotum,  and  to  the  tuber  ischii  and 
sphincter  ani  (Lockwood).  The  last-- named  attachments 
serve  to  explain  the  occasional  passage  of  the  testis  beyond 
the  scrotum  into  the  perineum  (testis  in  perineo).  In 
one  example  of  this  condition  I  found  it  necessary  to 
divide  a  band  passing  from  the  tuber  ischii  to  the  testis 
before  I  could  place  the  gland  in  the  scrotum. 

Following  the  gubernaculum  upwards,  it  is  attached, 
first  of  all,  to  the  vaginal  process,  which,  therefore, 
descends  before  the  testis,  then  to  the  gland  and  epi- 
didymis, and,  lastly,  to  the  peritoneum  about  the  bowel 
(caecum,  ileum,  or  mesentery  on  the  right  side,  and 
sigmoid  flexure  on  the  left  side).  The  latter  connec- 
tions serve  to  explain  the  condition  of  infantile  hernia, 
in  which  a  bag  or  diverticle  of  peritoneum  is  drawn 
down  into  the  scrotum  after  the  testis  (Lockwood). 
This  diverticle  can  then  become  the  sac  of  a  hernia. 

The  vaginal  process  is  often  found  open  at  birth, 
but  it  is  more  usually  found  cut  off  from  the  peritoneal 
cavity,  the  portion  thus  isolated  forming  the  tunica 
vaginalis.  This  vaginal  process  will  have  a  narrowed 
part  or  neck,  as  it  passes  along  the  inguinal  canal,  and 
will  be  free  to  enlarge  again  on  reaching  the  scrotum. 
The  manner  in  which  it  is  cut  off  is  as  follows.  It  be- 
comes obliterated  in  two  places,  at  the  internal  ring 
and  at  a  spot  just  above  the  epididymis,  the  obliteration 
usually  beginning  at  the  higher  point  first.  Supposing 
obliteration  to  have  taken  place  at  these  two  points, 
the  vaginal  process  between  them  will  he  represented 
by  an  isolated  tube.  This  soon  shrinks,  closes,  and 
dwindles  to  an  insignificant  fibrous  cord.  It  may, 
however,  remain  patent  in  part,  and  if  fluid  accumu- 
lates in  this  patent  portion,  an  "encysted  hydrocele  of 
the  cord  "  is  produced.  As  regards  the  mode  of  closure, 
three  contingencies  may  happen,  each  giving  rise  to  a 
particular  form  of  hernia  :  (1)  The  "  process"  may  not 
close  at  all ;  (2)  it  may  close  at  the  upper  point  only  ; 
and  (3)  it  may  close  at  the  lower  point  only. 

(l)  When  the  vaginal  process  is  entirely  open,  gut 
can  readily  descend  at  once  into  the  scrotum.     Such  a 


304  Surgical  Applied  Anatomy.   [Chap-xvi. 

condition  is  called  a  congenital  hernia,      Here  the 

intestine  is  found  to  occupy  a  large  sac  of  the  peri- 
toneum, the  open  orifice  of  which  is  placed  at  the  in- 
ternal inguinal  ring.  The  neck  of  the  sac  is  long  and 
narrow,  the  parts  around  have  not  been  disturbed  to 
permit  the  bowel  to  pass,  and  the  actual  sac  itself  is 
very  thin.  It  is  on  account  of  these  anatomical  con- 
ditions that  the  effects  of  strangulation  fall  as  a  rule 
heavier  upon  this  form  of  hernia  than  upon  the  corre- 
sponding acquired  form.  The  term  "  congenital "  is 
misleading,  as  the  hernia  is  very  rarely  present  at  birth, 
although  it  is  common  in  early  life. 

(2)  When  the  process  is  closed  only  at  the  internal 
ring  the  unduly  large  tunica  vaginalis  is  found  to  ex- 
tend up  to  that  orifice.  Behind  this  processus  or  tunica 
vaginalis  a  diverticle  of  peritoneum  is  drawn  down  into 
the  scrotum  by  the  gubernaculum,  and  becomes  the 
sac  of  a  hernia  (Lockwood).  This  is  known  as  an  in- 
fantile or  encysted  hernia.  In  such  a  case  the 
tunica  vaginalis  lies  in  front  of  the  sac,  and  therefore  three 
layers  of  peritoneum  would  have  to  be  cut  through  be- 
fore the  gut  could  be  reached.  The  term  "  infantile  " 
was  given  to  this  rupture  because  the  first  cases  re- 
ported were  met  with  in  infants  ;  the  term  "  encysted," 
because  the  hernial  sac  was  considered  to  be  enclosed  by 
the  sac  of  the  tunica  vaginalis.  The  condition  of  parts 
that  favours  the  development  of  this  rupture  serves  also 
to  explain  those  anomalous  cases  of  congenital  hernia 
that  appear  suddenly  and  for  the  first  time  in  adult 
life.  Here,  under  some  unwonted  exertion,  the  peri- 
toneum that  separates  the  large  tunica  vaginalis  from 
the  general  peritoneum  at  the  internal  ring  gives  way, 
and  the  gut  at  once  passes  into  the  cavity  beyond,  and 
so  appears  in  the  condition  of  a  congenital  hernia. 

The  infantile  hernia  also  includes  cases  in  which 
the  sac  descends  behind  an  entirely  unclosed  vaginal 
process. 

(3)  In  the  last-named  circumstance  a  tubular  pro- 
cess of  peritoneum  leads  down  as  far  as  the  top  of  the 
testicle    and  there  ends,  the  normal  tunica  vaginalis 


Chap,  xvi.]  The  As  do  me?:. 


v^D 


being    beyond.     Hernia   into   this    process   is   called   a 
hernia  into   the  funicular  process. 

In  the  first  of  these  forms  the  testicle  is  quite  en- 
veloped in  the  hernia.  In  the  second  and  third  forms, 
as  well  as  in  the  acquired  form,  it  is  to  be  felt  quite  dis- 
tinct from  the  rupture,  being  actually  behind  and  below 
it.  A  congenital  hernia  may  form  in  cases  where  the 
testicle  has  not  descended  at  all.  In  such  instances 
the  vaginal  process  may  occupy  the  would-be  canal, 
and  along  this  process  a  hernia  may  descend.  It  is 
well  known  that  the  testicle  may  make  its  first  appear- 
ance in  the  scrotum  months  and  even  years  after 
birth.  In  such  cases  the  vaginal  process  may  he  nor- 
mally developed  at  birth  (i.e.  may  occupy  the  scrotum), 
or  it  may  be  abortive. 

In  the  foetus  the  inguinal  canal  is  relatively  much 
shorter  than  it  is  in  the  adult.  As  the  pelvis  developes, 
however,  the  relations  of  the  canal  approach  more  to 
the  normal.  In  the  congenital  hernia  the  relations  of 
the  canal  are  not  disturbed  as  they  are  in  the  acquired 
form.  Thus  it  happens  that  such  ruptures  have  long 
and  narrow  necks,  and  the  difficulty  in  steadying  this 
neck  constitutes  one  of  the  special  obstacles  in  the 
effectual  reduction  of  the  hernia. 

There  is  another  possible  congenital  defect  that  may 
predispose  to  hernia,  viz.  an  abnormally  long  mesentery. 
If,  in  the  dead  subject,  the  inguinal  canal  lie  opened  up, 
and  an  at  temp;  made  to  draw  a  piece  of  gut  down  from 
the  abdomen  into  the  scrotum,  it  will  be  found  that  it 
cannot  be  done,  owing  to  the  shortness  of  the  mesentery. 
In  any  case  of  scrotal  hernia,  therefore,  the  mesentery 
must  become  lengthened,  and  it  is  a  question  whether 
or  not  an  abnormally  long  mesentery  may  exist  as  a 
congenital  defect,  and  so  predispose  the  patient  to  rup- 
ture.    More  information  is  required  upon  the  subject. 

The  inguinal  eanal  in  the  female  is  much 
smaller  and  narrower,  although  a  trifle  longer,  than  it 
is  in  the  male.  It  is  occupied  by  the  round  ligament, 
and  offers  such  slight  inducement  to  the  formation  of 
a  rupture,   that  acquired  inguinal    hernia  is  as  ran? 

u 


306  Surgical  Applied  Anatomy.   [Chap. xvi. 

among  females  as  it  is  common  among  men.  In  the 
female  foetus  a  process  of  peritoneum  descends  for  a 
little  way  along  the  round  ligament.  It  corresponds 
to  the  processus  vaginalis  of  males,  and  is  known  as  the 
canal  of  Nuck.  If  this  process  remains  patent,  as  it 
not  infrequently  does,  it  may  lead  to  a  rupture  that 
corresponds  to  the  congenital  hernia  of  males.  Indeed, 
in  quite  early  life  the  inguinal  rupture  is  about  the  only 
form  met  with  in  female  children,  if  exception  be  made 
of  umbilical  hernia.  In  all  such  instances  of  early 
inguinal  hernia  the  gut  has  travelled  down  a  patent 
canal  of  Nuck. 

It  only  remains  to  be  said,  that  in  endeavouring  to 
reduce  an  inguinal  hernia  by  taxis  the  thigh  should 
be  flexed  and  adducted,  for  in  that  position  the  ab- 
dominal parietes  that  bound  the  inguinal  canal  are 
the  most  relaxed.  This  position  of  the  thigh  affects 
the  inguinal  region  mainly  through  the  attachments 
of  the  fascia  lata  to  Poupart's  ligament. 

In  herniotomy  an  incision  is  made  along  the 
middle  of  the  tumour  and  in  its  long  axis,  being  so 
arranged  that  its  centre  shall  correspond  to  the  external 
ring.  The  superficial  external  pudic  artery  is  usually 
divided  in  the  operation.  It  is  impossible  to  distinguish 
the  various  layers  of  tissue  that  cover  the  hernia,  the 
only  one,  as  a  rule,  that  is  recognisable  being  the  layer 
from  the  cremaster.  In  dividing  the  constriction  it  is 
usually  recommended  to  cut  upwards  in  all  forms  of 
inguinal  hernia.  The  only  vessel  in  risk  of  being 
damaged  is  the  deep  epigastric.  In  the  oblique  form  of 
rupture  an  incision  directly  upwards  would  quite  avoid 
this  artery  ;  but  in  a  direct  hernia,  where  there  is  reason 
to  suppose  that  the  vessel  is  in  close  connection  with 
the  neck  of  the  sac,  it  is  well  that  the  incision  be  directed 
a  little  inwards  as  well  as  upwards.  It  should  be  remem- 
bered that  the  incision  required  to  relieve  a  constriction 
is,  if  properly  applied,  of  the  most  insignificant  character. 

Femoral  hernia. — In  this  form  of  rupture  the 
gut  leaves  the  abdomen  through  the  femoral  ring  and 
passes  down  into  the  thigh  along  the  crural  canal.     The 


Chap,  xvi.]  The  Abdomen.  307 

name  "crural  canal"  is  given  to  the  narrow  interval 
between  the  femoral  vein  and  the  inner  wall  of  the 
crural  sheath.  Like  the  inguinal  canal,  it  is  a  potential 
rather  than  an  actual  canal,  and  exists  only  when  the 
sheath  has  been  separated  from  the  vein  by  dissection 
or  by  a  hernial  protrusion  of  some  kind.  The  canal 
is  funnel-shaped,  about  \  an  inch  in  length,  and  ends 
opposite  the  saphenous  opening.  Femoral  hernias  are 
always  acquired,  and  possess  a  sac,  made  by  themselves 
out  of  the  parietal  peritoneum  covering  the  crural 
ring  and  its  vicinity.  The  canal  is  larger  in  women 
than  in  men,  and  thus  it  happens  that  this  species  of 
rupture  is  much  more  common  in  the  former  sex.  The 
tendency  to  this  hernia  in  women  appears  also  to  be 
increased  by  the  weakening  effects  of  pregnancy  upon 
the  abdominal  walls.  As  the  gut  descends  it  pushes 
in  front  of  it  its  sac  of  peritoneum  and  the  septum  crurale 
(the  name  given  to  the  subserous  tissue  that  covers 
in  the  femoral  ring)  and  enters  the  crural  sheath.  The 
adhesions  of  the  sheath  limit  its  downward  progress 
when  it  has  travelled  about  \  an  inch,  and  it  therefore 
passes  forwards  through  the  saphenous  opening,  pushing 
before  it  the  cribriform  fascia.  It  then  receives  a 
covering  from  the  superficial  fascia  and  the  skin.  Owing 
to  the  rigidity  of  the  structures  about  the  femoral  ring, 
the  neck  of  the  sac  must  always  be  small.  For  similar 
reasons  its  dimensions  while  in  the  femoral  canal  must 
of  necessity  be  insignificant,  but  when  once  it  has 
escaped  through  the  saphenous  opening  the  loose  sub- 
cutaneous fasciaa  of  the  groin  afford  it  ample  opportuni- 
ties for  increase.  When  the  hernia  has  passed  through 
the  saphenous  opening  it  tends  to  mount  upwards 
over  Poupart's  ligament,  in  the  direction  of  the  anterior 
superior  iliac  spine.  Even  when  it  overlaps  the  ligament 
considerably  it  can  hardly  be  mistaken  for  an  inguinal 
hernia,  since  it  must  always  lie  to  the  outer  side  of  the 
pubic  spine.  The  upward  tendency  of  a  femoral  hernia 
has  been  variously  explained.  It  has  been  ascribed 
to  a  supposed  curve  in  the  crural  canal,  the  concavity 
of  which   is   forwards.    Scarpa  believed  it  to   receive 


o 


08  Surgical  Applied  Anatomy.    [Chap.  xvi. 


its  direction  from  the  frequent  flexion  of  the  thigh. 
Probably  one  of  the  most  important  factors  in  the  matter 
is  the  unyielding  character  of  the  lower  edge  of  the 
saphenous  opening.  This  edge  tends  to  direct  the 
gut  forwards,  while  the  traction  upon  the  mesentery, 
that  is  inevitable  as  the  rupture  proceeds,  may  be  con- 
ceived as  favouring  an  upward  direction.  The  coverings 
of  a  hernia  that  has  found  its  way  beneath  the  skin 
are  often  very  scanty. 

Relations. — When    a    hernia    occupies    the    crural 
canal  there  are  in  front  of  it  the  skin  and  superficial 
fasciae,  the  iliac  part  of  the  fascia  lata,  the  crural  arches, 
the  cribriform  fascia,  and  the  anterior  wall  of  the  crural 
sheath.     Behind  are  the  posterior  wall  of  the  crural 
sheath  and  pubic  portion  of  the  fascia  lata,  the  pectineus 
muscle,  and  the  bone.     The  boundaries  of  the  femoral 
ring  are,  in  front,   Poupart's  ligament  and  the   deep 
crural  arch ;    behind,  the  bone  covered  by  the  fascia 
lata  and  the  pectineus  ;  on  the  inner  side,  the  conjoined 
tendon,  Gimbernat's  ligament,  and  the  inner  part  of 
the  deep  crural  arch  ;    on  the  outer  side,  the  femoral 
vein  in  its  sheath.     The  spermatic    cord   lies    (in  the 
male)  just  above  the  anterior  border  of  the  ring,  and 
the  epigastric  artery  skirts  its  upper  and  outer  part. 
The  little  pubic  branch  of  this  artery  passes  round  the 
ring   to   ramify   over   Gimbernat's   ligament.     In   one 
case  out  of  three  and  a  half  the  obturator  artery  arises 
from   the   epigastric.     Out   of   one   hundred   and   one 
cases  where  the  vessel  so  arose  it  reached  its  destination 
in  fifty-four  instances  by  passing  along  the  outer  side 
of  the  crural  ring,  a  position  quite  free  from  danger 
in  herniotomy.     In  thirty-seven  cases  it  passed  backwards 
across  the  ring,  and  in  ten  instances  round  its  inner 
border  (R.  Quain).     When  in  the  last-named  position 
the  vessel  could  hardly  escape  being  wounded  in  the 
operation    upon    a    femoral    hernia.     Indeed,    several 
cases  have   been  recorded  of  fatal  haemorrhage  from 
this    abnormal    vessel    in    such    operations.      In    one 
instance    the    pulsations  of  the  abnormal  artery  were 
felt  before  the  parts  were  divided.     In  addition  to  the 


Chap,  xvi.]  The  A  boom  ex.  309 

vessels  about  the  ring  there  is  also  a  pubic  vein,  which, 
ascending  from  the  obturator  vein  in  the  thyroid  fora- 
men, enters  the  external  iliac  vein.  Its  relation  to  the 
crural  ring  varies  in  the  same  way  as  the  abnormal 
artery  last  named. 

The  size  of  the  femoral  canal  and  the  degree  of 
tension  of  its  orifices  varies  greatly  with  the  position 
of  the  limb.  If  the  thigh  lie  extended,  abducted,  and 
rotated  outwards,  these  parts  are  made  very  tense, 
while  they  are  the  most  lax  when  the  limb  is  flexed, 
adducted,  and  rotated  inwards.  It  is  consequently 
in  the  latter  position  that  the  thigh  should  lie  placed 
when  the  taxis  is  being  attempted.  In  herniotomy 
the  incision  is  made  along  the  inner  side  of  the  tumour, 
and  is  so  arranged  that  its  centre  corresponds  to  about 
the  upper  part  of  the  saphenous  opening.  The  con- 
striction is  usually  at  the  neck  of  the  sac,  and  caused 
by  Gimbernat'a  ligament.  It  is  divided  by  an  incision 
directed  upwards  and  inwards. 

Obturator  hernia. — In  this  form  the  gut, 
pushing  before  it  the  peritoneum,  the  sub-peritoneal 
fat,  and  the  pelvic  fascia,  escapes  through  the  obturator 
canal.  The  direction  of  this  canal  is,  from  behind, 
downwards,  forwards  and  inwards. 

Beyond  the  canal  the  hernia  may  pass  between  the 
obturator  membrane  and  the  obturator  externus  muscle 
and  remain  deeply  placed,  or  it  may  make  its  way  through 
the  muscle  or  emerge  above  it  and  lie  then  covered 
by  the  pectineus  and  adductor  brevis.  The  obturator 
artery  is,  us  a  rule,  at  the  outer  and  posterior  part  of 
the  sac.  It  is  very  rarely  in  front  of  it.  The  obturator 
nerve  is  generally  found  to  the  outer  side  of  the  sac, 
less  commonly  it  is  in  front  of  it.  The  proximity  of 
the  nerve  renders  it  very  liable  to  Ik?  pressed  upon, 
a  id  pain  along  the  nerve  is  often  a  marked  feature 
of  the  rupture.  The  hernia  presents  beneath  the 
pectineu3  muscle,  to  the  inner  side  of  the  capsule  of  the 
hip,  behind  and  to  the  inner  side  of  the  femoral  vessels, 
and  to  the  outer  side  of  the  adductor  longus  tendon. 
Pain   on   moving   the   hip   i<   generally  a   conspicuous 


310  Surgical  Applied  Anatomy.    [Chap.  xvi. 

symptom.  The  obturator  externus  may  be  made 
tense  by  rotation  inwards  of  the  slightly  abducted  thigh. 
This  hernia  is  much  more  common  in  females  ;  and 
it  is  worthy  of  note  that  the  orifice  of  the  obturator 
canal  can  be  examined,  to  some  extent,  through  the 
vagina.  Professor  Wood  reports  a  remarkable  case 
where  a  hernial  protrusion  of  a  part  of  the  adductor 
longus  through  a  rent  in  its  aponeurosis  was  mistaken 
for  an  obturator  hernia. 

Rare  forms  of  hernia. — In  -perineal  hernia 
the  sac,  covered  by  the  recto-vesical  fascia,  escapes 
through  the  anterior  fibres  of  the  levator  ani  muscle, 
between  the  prostate  and  the  rectum.  In  the  ischio- 
rectal hernia  the  protrusions  take  place  into  the  ischio- 
rectal fossa.  In  pudendal  hernia  the  sac  lies  in  the 
posterior  inferior  half  of  the  labium  pudendi,  escaping 
between  the  ascending  ramus  of  the  ischium  and  the 
vagina;  it  has  been  mistaken  for  a  cyst.  In  sciatic 
hernia  the  gut  escapes  through  the  great  sacro-sciatic 
notch  in  front  of  the  internal  iliac  vessels,  above  or 
below  the  pyriformis,  and  appears  under  the  gluteus 
maximus  muscle.  As  regards  umbilical  hernia,  nothing 
remains  to  be  added  to  what  has  been  already  said 
(page  288),  save  that  the  sac  from  its  position  nearly 
always  contains  omentum,  and  may  contain  stomach. 
In  lumbar  hernia  the  gut  escapes  in  front  of  the  quad- 
ratus  lumborum  muscle,  and  appears  on  the  surface 
through  the  triangle  of  Petit  (the  gap  between  the 
latissimus  dorsi  and  external  oblique  muscles),  and 
therefore  just  above  the  highest  point  of  the  iliac  crest. 
The  sac  must  either  force  before  it  or  (in  cases  of  injury) 
come  through  the  fascia  lumborum  and  internal  oblique 
muscles,  since  those  structures  form  the  floor  of  the 
triangle.  The  hernia  may  escape  through  the  "  upper 
lumbar  triangle  " — a  gap  near  the  last  rib  where  the 
aponeurosis  of  the  transversalis  is  covered  only  by  the 
latissimus  dorsi.  Macready  {Lancet,  Nov.  8th,  1890) 
has  collected  twenty-five  examples  of  this  hernia. 
Diaphragmatic  hernice  may  be  congenital  or  acquired. 
The  former  variety  is  by  far  the  more  common,  and  is 


Chap,  xvi.]  The  Abdomen.  3 1 1 

due  to  simple  arrest  in  the  development  of  the  diaphragm 
and  persistence  of  the  original  connection  between  the 
thorax  and  abdomen.  The  acquired  form  usually 
follows  a  laceration  of  the  diaphragm  from  injury. 
In  any  case  some  of  the  abdominal  viscera  are  protruded, 
through  the  gap  in  the  midriff,  into  the  thoracic  cavity. 
Owing  to  the  presence  of  the  liver  on  the  right  side, 
these  hernias  are  much  more  common  on  the  left  side. 
Of  the  organs,  the  stomach  is  the  most  frequently  dis- 
lodged, then  the  transverse  colon,  omentum,  small 
gut,  spleen,  liver,  pancreas,  and  kidneys,  in  the  order 
named  (Leichtenstern).  The  hernia  may  escape  through 
the  foramen  for  the  gullet,  but  never  through  that  for 
the  vena  cava,  nor  through  the  hiatus  aorticus.  The 
parts  commonly  selected  are  the  connective  tissue 
intervals  between  the  sternal  and  costal  origins  of  the 
diaphragm  in  front  and  its  vertebral  and  costal  origins 
behind.     These  hernia?  are  more  common  in  males. 

Posterior  abdominal  parietes. — The  lateral 
and  posterior  walls  of  the  abdomen  are  lined  inside  with 
two  fascia?,  the  transversalis  and  iliac.  The  transversalis 
fascia  lines  the  whole  of  the  transversalis  muscle,  and  is 
much  thicker  below  than  above.  Above  it  joins  the 
fascia  covering  the  diaphragm,  while  below  it  is  at- 
tached to  the  iliac  crest  and  to  the  whole  of  Poupart's 
ligament,  save  at  that  spot  where  it  passes  into  the 
thigh  to  form  the  anterior  layer  of  the  crural  sheath. 
The  iliac  fascia  encloses  the  ilio-psoas  muscle,  the  part 
over  the  psoas  being  the  thinner.  This  part  is  attached 
on  the  inner  side  to  the  sacrum,  and  to  the  spine  at  the 
points  corresponding  to  the  psoas  origin.  Above,  it  is 
attached  to  the  ligamentum  arcuatum  internum,  and 
on  the  outer  side  to  the  anterior  layer  of  the  lumbar 
fascia  along  the  outer  edge  of  the  psoas.  Below,  the 
fascia  encloses  the  iliaeus,  and  is  attached  to  the  iliac 
crest,  to  the  pelvic  brim,  and  to  Poupart's  ligament, 
save  at  that  part  where  the  membrane  passes  beneath 
the  ligament  to  form  the  posterior  wall  of  the  crural 
sheath.  It  follows  the  ilio-psoas  muscle  to  its  insertion, 
and  ends  by  blending  with  the  fascia  lata. 


312  Surgical  Applied  Anatomy.    [Chap.  xvi. 

The  arrangement  of  these  fasciae  greatly  influences 
the  progress  and  direction  of  abscess.  Thus  an  abscess 
beneath  the  transversalis  fascia  will  be  very  definitely 
enclosed.  If  it  progresses  backwards  it  will  be  stopped 
at  the  outer  edge  of  the  psoas  muscle.  If  it  spreads 
downwards  it  will  be  arrested  by  the  attachments  of 
the  fascia  to  the  iliac  crest  and  to  Poupart's  ligament, 
and  will  be  unable  to  spread  (unless  the  fascia  be  pierced) 
into  either  the  pelvis  or  the  thigh.  On  the  inner  side 
it  will  be  checked  at  the  middle  line  ;  and  above,  although 
it  will  meet  with  no  actual  resistance,  it  would  be  in- 
disposed to  spread,  since  its  movements  would  be  against 
gravity.  Thus  it  happens  that  collections  so  placed 
point  either  just  above  the  iliac  crest  or  Poupart's  liga- 
ment, or  run  down  along  the  spermatic  cord  and  dis- 
tend the  inguinal  canal. 

The  iliac  fascia  encloses  the  ilio-psoas  in  a  very  dis- 
tinct osseo-aponeurotic  space.  Between  the  fascia 
and  the  muscle  (especially  its  iliac  division)  there  is 
a  good  deal  of  loose  connective  tissue,  and  thus  every 
facility  is  offered  for  the  progress  of  subfascial  abscesses 
in  this  region.  The  osseo-aponeurotic  space  is  practic- 
ally closed  on  all  sides  within  the  abdomen,  and  is 
only  open  below  where  the  fascia  passes  with  its 
muscle  into  the  thigh.  This  opening  being  at  the 
most  dependent  part  of  the  space,  it  follows  that  the 
psoas  or  iliac  abscess  very  commonly  points  on  the 
upper  part  of  the  thigh,  just  to  the  outer  side  of  the 
femoral  vessels.  An  abscess  in  the  iliac  fossa,  although 
most  likely  to  reach  the  thigh,  might  mount  up  to  the 
superior  attachments  of  the  fascia,  and  point  at  the  iliac 
crest  or  at  the  outer  part  of  Poupart's  ligament.  Or  it 
may  disregard  the  inner  attachments  of  the  fascia  and 
gravitate  into  the  pelvis.  If  the  patient  should  occupy 
for  long  the  recumbent  posture,  there  is  no  reason  why 
it  should  not  extend  upwards  along  the  psoas  muscle. 

The  term  iliac  abscess,  however,  is  often  applied  to 
collections  that  are  not  within  the  space  formed  by  the 
iliac  fascia,  but  that  are  situated  rather  in  the  subserous 
connective  tissue.     This  tissue  is  very  extensive  in  the 


Chap,  xvi.]  The  Abdomen.  313 

iliac  fossa,  and  favours  the  formation  of  large  purulent 
collections.  Kcenig's  experiments  of  injecting  fluid 
into  this  subserous  space  show  that  an  abscess  so  placed 
may  spread  in  any  direction  by  simply  dissecting  off 
the  peritoneum.  Clinically,  however,  such  collections 
are  greatly  limited  by  gravity.  They  are  apt  to  remain 
in  the  iliac  fossa,  bulging  out  the  abdominal  wall  just 
above  Poupart's  ligament,  and  occupying  the  angle 
formed  by  the  union  of  the  iliac  and  transversalis  fascia.'. 
In  some  cases  they  are  disposed  to  extend  into  the  pelvis. 

The  abscess,  when  in  the  subserous  tissue,  is 
brought  in  close  contact  with  certain  of  the  viscera, 
especially  with  the  caecum  and  sigmoid  flexure,  and 
into  these  portions  of  the  colon  it  may  open.  Thus,  I 
have  seen  a  case  of  iliac  abscess  due  to  pelvic  necrosis 
that  opened  into  t lie  sigmoid  flexure,  and  at  the  same 
time  discharged  through  sinuses  about  the  groin.  In 
this  case  some  pus  passed  by  the  anus,  while  on  the 
other  hand  some  fa?cal  matter  escaped  by  the  groin. 
Retro-peritoneal  abscesses  in  the  pelvis  (pelvic  cellulitis) 
may  mount  up  into  the  iliac  fossae,  may  appear  as  "  iliac 
abscesses,"'  and  may  ultimately  discharge  themselves 
by  many  openings  in  the  lower  parts  of  the  anterior 
abdominal  wall. 

It  may  lie  well  to  note  that  the  common  and 
external  iliac  vessels,  the  lymphatics,  and  the  ureters 
are  outside  the  iliac  fascia,  and  rest  upon  its  abdominal 
surface,  while  the  anterior  crural  nerves  and  abdominal 
parts  of  the  Lumbar  nerves  are  within  theosseo-apbneur- 
otic  space.  Thus  the  suprafascial  abscess  may,  with 
little  difficulty,  reach  the  thigh  by  following  the  iliac 
vessels;  while  the  subfascial  collection  would  pursue 
the  anterior  crural  nerve. 

A  psoas  abscess,  or  abscess  within  the  fascial 
sheath  of  the  psoas  muscle,  is  usually  due  to  spinal 
caries,  although  it  may  appear  independently  of  that 
disease.  If  tic  lumbar  spine  be  involved  the  matter 
can  pass  directly  into  the  substance  of  the  muscle. 
which  it  will  more  or  less  entirely  destroy.  U  the  mis- 
chief be  in  the  dorsal  -pine,  the  matter  gravitates  along 


314  Surgical  Applied  Anatomy.   [Chap.  xvi. 

the  front  of  the  column  until  it  reaches  the  diaphragm, 
which  it  pierces  by  an  inflammatory  process.  It  is 
now  brought  into  relation  with  the  heads  of  the  psoas, 
and  has  to  pass  through  a  narrow  strait.  "  It  is 
prevented  from  enlarging  on  the  fore  part  by  the  liga- 
menta  arcuata,  and  at  the  back  by  the  spine  and  lowest 
rib ;  hence,  in  order  to  proceed  it  has  to  force  its  way 
in  the  line  of  the  psoas  muscle.  That,  however,  can 
only  be  done  by  penetrating  into  its  interior.  It  ac- 
complishes this,  in  the  first  place,  by  inserting  its  most 
advanced  part,  like  a  wedge,  between  the  two  origins 
(viz.  from  the  bodies  of  the  vertebrae  and  from  the 
corresponding  transverse  processes) :  it  then  splits  and 
distends  the  fibres,  so  as  to  form  a  cavity  for  the  re- 
ception of  the  pus  .  .  .  and  the  psoas  at  length  is  con- 
verted more  or  less  thoroughly  into  an  abscess  "  (Shaw). 
The  pus,  following  the  muscle,  at  last  reaches  the  thigh, 
and  usually  points,  just  below  the  groin,  to  the  outer 
side  of  the  femoral  vessels. 

The  abscess,  however,  often  shows  much  variation. 
It  may  avoid  the  psoas,  or  leave  it  when  once  it  has 
entered  it,  and  make  its  way  into  the  lumbar  region 
to  find  an  exit  in  the  loin.  Or  it  may  extend  into  the 
iliac  fossae  and  open  above  the  groin,  or  mount  up  over 
the  iliac  crest  and  discharge  in  the  gluteal  region. 
It  may  pass  along  the  inguinal  canal  and  be  mis- 
taken for  a  hernia.  It  may  sink  into  the  pelvis,  and 
may  open  into  the  bladder,  or  discharge  itself  through 
the  great  sciatic  foramen,  or  through  a  sinus  in  the 
perineum.  Some  of  the  latter  cases  have  led  to  much 
confusion  in  diagnosis,  since  there  would  appear  to  be 
little  connection  between  caries  of  the  spine  and  a 
perineal  abscess. 

Lumbar  region.— The  muscles  that  form  the 
lateral  and  posterior  walls  of  the  abdomen,  and  that  fill 
in  the  interval  between  the  iliac  crest  and  the  lowest 
rib,  are  the  external  oblique  and  latissimus  dorsi,  the 
internal  oblique,  the  trans versalis  muscle  and  fascia 
lumborum,  the  erector  spinse  and  quadrat  us  lumborum. 
The  external  oblique  and  latissimus  dorsi  muscles 


chap,  xvi.]  The  Abdomen.  315 

are  separated  by  a  small  triangular  interval  below  (the 
triangle  of  Petit),  but  above  they  overlap.  The  interval 
between  these  two  muscles  may  be  represented  by  a 
line  drawn  vertically,  upwards  from  the  middle  of  the 
crest  of  the  ilium.  The  outer  edge  of  the  quadratus 
lumborum  corresponds  to  this  line,  just  above  the  iliac 
crest ;  but  as  the  border  of  the  muscle  slopes  upwards 
and  backwards,  it  may  be  about  an  inch  behind  the 
line,  at  a  point  midway  between  the  crest  and  the  last 
rib.  The  edge  of  the  muscle  is  overlapped  by  the  in- 
ternal oblique,  and  its  inner  half  or  two-thirds  is  over- 
lapped by  the  erector  spina?.  The  subcutaneous  tissue 
in  the  lumbar  region  is  very  extensive,  and  is  a  favourite 
locality  for  chronic  abscess.  The  looseness  and  extent 
of  the  tissue  also  permit  of  large  extravasations  of  blood. 
It  is  in  the  muscles  and  fascia  along  the  spine  in  this 
region  that  the  rheumatic  affection  known  as  lumbago 
has  its  seat. 

Between  the  last  rib  and  the  iliac  crest  is  stretched 
the  dense  fascia  lumborum,  the  posterior  aponeurosis 
of  the  transversalis  muscle.  It  is  pierced  near  the  rib 
by  the  last  intercostal  artery  and  nerve,  and  near  the 
ilium  by  the  ilio-hypogastric  nerve  and  its  accompany- 
ing artery.  It  is  along  these  structures  that  an  abscess 
may  possibly  find  its  way  through  the  fascia  in  certain 
cases.  The  fascia  divides  behind  into  three  layers,  to 
enclose  in  definite  spaces  the  quadratus  and  erector 
spina?  muscles.  Within  these  spaces  or  compartments 
suppuration  may  be  for  some  time  limited.  A  lumbar 
abscess  commencing  in  some  adjacent  part,  as  in  the 
spine  or  in  the  loose  tissue  around  the  kidneys, 
usually  spreads  backwards  by  piercing  the  fascia 
lumborum  or  the  quadratus  muscle.  It  then  finds  its 
way  through  the  internal  oblique,  and  appears  on  the 
surface  between  the  external  oblique  and  latissimus 
dorsi  muscles,  and  at  the  outer  border  of  the  erector 
spina?.  It  should  be  noted  that  the  quadratus  muscle 
is  very  thin,  and  offers  little  resistance  to  protrusions 
from  within,  while  a  great  part  of  the  muscle  is  firmly 
supported  behind  by  the  erector  spina?. 


316  Surgical  Applied  Anatomy.    [Chap. xvi. 

The  author's  operation  for  caries  of  the 
lumbar  vertebrae.— The  lumbar  vertebrae,  and, 
possibly,  the  last  dorsal,  may  be  reached  by  an  incision 
through  the  loin.  A  vertical  cut  is  made  along  the 
outer  edge  of  the  erector  spinas  muscle.  The  fibres  of 
that  muscle  having  been  drawn  aside,  the  middle  layer 
of  the  fascia  lumborum  is  incised,  and  the  quadratus 
lumborum  is  exposed.  This  muscle  is  divided  vertically, 
and  then  the  front  of  the  vertebrae  may  be  reached  by 
introducing  the  finger  under  the  psoas  muscle.  Through 
this  incision  the  author  has  removed  the  whole  of  the 
body  of  the  first  lumbar  vertebra  that  had  been  separated 
as  a  sequestrum.  {Med.-Chir.  Trans.,  1884.)  The 
lumbar  arteries  are  avoided  by  keeping  close  to  the 
transverse  process  of  the  vertebrae.  Through  this 
incision  a  psoas  abscess  may  be  most  conveniently 
opened. 


CHAPTER    XVII. 


THE     ABDOMINAL     VISCERA. 


The  peritoneum. — Certain  of  the  viscera,  as, 
for  example,  the  stomach,  spleen,  and  small  intestines, 
are  so  closely  invested  with  peritoneum  that  they  could 
not  be  wounded  without  that  membrane  being  wounded 
also.  Inflammatory  affections  of  such  viscera  are  also 
very  apt  to  involve  the  peritoneum.  Other  organs, 
such  as  the  kidney,  descending  colon,  pancreas,  etc.. 
are  so  imperfectly  covered  with  the  serous  membrane 
that  a  wound  of  those  organs  need  not  involve  it,  nor 
need  it  be  implicated  in  even  extensive  inflammatory 
changes.  Large  abscesses  may,  for  instance,  form 
about  the  kidney  and  discharge  themselves  through 
the  skin  without  any  peritonitis  being  induced.  Spon- 
taneous perforation  of  the  small  intestine  must  involve 
the  i)eritoneum,  while,  on  the  other  hand,  the  caecum 
and  descending  colon  may  become  perforated,  and  the 
matter  escape  into  the  subserous  tissue  without  the 


Chap,  xvii.]      The  Abdominal    Viscera.  317 

serous    membrane   being  in  any  way   involved.      It  is 

noteworthy  in  connection  with  bacterial  infection  that 
it  is  singularly  easy  to  set  14)  inflammation  of  the  perito- 
neum if  the  membrane  be  approached  from  its  inner 
surface,  hut  comparatively  difficult  if  it, be  approached 

from  without.  Thus  a  small  puncture  of  the  membrane 
may,  on  the  one  hand,  lead  to  fatal  peritonitis,  while, 
on  the  other,  it  may  be  extensively  torn  from  its  attach- 
ments (as  in  ligaturing  the  common  iliac  artery  from 
the  side)  without  any  peritonitis  following.  Or,  again, 
a  little  pus  escaping  on  the  inner  surface  of  the  mem- 
brane may  lead  to  inflammation,  while  the  outer  surface 
may  be  bathed  with  pus  for  a  long  while  (as  in  large 
perirenal  abscesses)  without  any  peritonitis  being- 
produced.  Inflammation  of  the  peritoneum  may  lead 
to  the  formation  of  a  great  variety  of  hands  and 
adhesions,  beneath  which  pieces  of  intestine  may  be 
caught  and  strangulated. 

The  peritoneum  will  allow  of  very  considerable 
stretching  if  only  that  stretching  be  effected  gradually. 
This  is  frequently  seen  in  cases  of  gradual  distension 
of  the  bowel,  in  the  formation  of  the  sac  in  hernia,  and 
in  the  growth  of  retro-peritoneal  tumours.  Abrupt 
stretching  of  the  membrane  leads  to  certain  rupture  of 
it.  The  parietal  peritoneum  may  be  ruptured  by 
violence  without  damage  to  any  of  the  viscera. 

The  great  omentum  is,  from  its  position,  very 
apt  to  be  wounded.  In  small  wounds  of  the  front  of 
the  belly  it  very  often  protrudes  and  acts'as  an  excellent 
plug  to  prevent  the  escape  of  other  and  more  important 
structures.  It  is  often  found  in  hernia,  especially  in 
umbilical  hernia,  where  it  is  almost  constant.  Its  limits 
vary,  and  it  has  an  inclination  to  the  left  side.  This 
depends  upon  the  fact  that  the  omentum  is  developed 
from  the  meso-gaster,  and  accounts  for  the  fact  that 
hernise  containing  omentum  are  much  more  common 
on  the  left  side.  The  omentum,  like  the  other  parts  of 
the  peritoneum,  is  apt  to  inflame,  and  to  contract 
adhesions  to  the  neighbouring  parts.  These  adhesions 
are  often  of  the  greatest  service  in  limiting  inflam- 


318  Surgical  Applied  Anatomy.  [Chap.  xvii. 

niatory  and  hemorrhagic  extravasations,  by  matting 
the  bowels  together  and  forming  spaces  between  them. 
In  perforation  of  the  bowels  from  disease,  an  opportune 
adhesion  of  the  omentum  over  the  aperture  may 
prevent  escape  of  the  intestinal  contents. 

Large  masses  of  tissue  may  be  nourished  through 
an  adherent  omentum.  Thus  when  the  proper  blood 
supply  of  an  ovarian  tumour  has  been  cut  off  by  twisting 
of  its  pedicle,  the  growth  may  be  nourished  through 
the  omentum,  if  that  structure  is  adherent  to  it. 
Rutherford  Morrison  proposes  to  relieve  congestion 
of  the  portal  circulation  by  setting  up  an  anastomosis 
between  the  omental  vessels  and  the  systemic  circulation. 
When  an  adhesion  between  the  omentum  and  parietal 
peritoneum  is  produced  artificially,  large  anastomotic 
vessels  open  up  and  communicate  with  the  vascular 
network  beneath  the  parietal  peritoneum,  thus  possibly 
relieving  tension  in  cases  of  obstructed  portal  circula- 
tion. In  cases  of  obesity  fat  collects  conspicuously  in 
the  great  omentum.  In  hernias  the  omentum  generally 
contracts  adhesions  to  the  sac,  and  becomes  irreducible, 
or  it  may  form  a  kind  of  second  sac  about  the  gut  itself 
("  omental  sac ").  The  end  of  the  omentum,  by  be- 
coming adherent  to  distant  parts,  as  to  the  pelvic  viscera, 
may  form  itself  into  a  firmly  attached  band,  beneath 
which  the  bowel  may  be  fatally  strangled.  In  like 
manner  the  intestine  has  been  strangulated  through 
slits  and  holes  that  have  developed  in  the  omentum, 
usually  as  a  result  of  inflammatory  adhesions.  When  the 
great  omentum  contains  much  fat  it  must  act  as  an 
excellent  protection  to  the  bowels,  and  must,  as  a  layer 
of  non-conducting  material,  help  to  maintain  the 
equality  of  their  temperature. 

The  mesentery. — The  parietal  attachment  of  the 
mesentery  is  liable  to  some  variation.  The  point  at 
which  this  attachment  commences  above  is  practically 
constant.  It  corresponds  with  the  ending  of  the  duo- 
denum, is  about  on  a  level  with  the  lower  border  of  the 
pancreas,  and  is  just  to  the  left  of  the  second  lumbar 
vertebra.      {See    page    332.)      From    this    point    the 


chap,  xvii]      The  Abdominal    Viscera.  319 

insertion  of  the  mesentery  follows  an  oblique  line  that 
runs  downwards  and  to  the  right,  crossing  the  great 
vessels,  and  then  ending  in  a  somewhat  uncertain 
manner  on  the  right  iliae  fossa.  Its  right  or  upper 
layer  is  continuous  with  the  under  layer  of  the  trans- 
verse meso-colon,  and  with  the  peritoneum  that  invests 
the  ascending  colon.  Its  left  or  lower  layer  joins  with 
the  serous  membrane  that  encloses  the  descending  colon, 
that  forms  the  sigmoid  mesentery,  and  that  descends 
over  the  lumbosacral  eminence  into  the  pelvis.  The 
parietal  attachment  of  the  mesentery  measures,  as  a 
rule,  about  o'  inches.  From  its  oblique  attachment 
it  follows  that,  when  haemorrhage  takes  place  in  the 
abdomen  on  the  right  side  of  the  mesentery,  the  blood 
first  is  conducted  into  the  right  iliac  fossa,  when  on  the 
left  Bide,  into  the  pelvis.  This  may  explain  the  circum- 
stance that  collections  of  blood  are  more  common  in  the 
right  than  in  the  left  iliac  fossa. 

The  length  of  the  mesentery  from  the  spine  to  the 
bowel  varies  in  different  parts  of  the  canal ;  its  average 
length  is  8  inches.  The  longest  part  is  that  which  goes 
t<>  the  coils  of  intestine  that  lie  between  a  point  6  feet 
from  the  duodenum,  and  a  point  11  feet  from  the  same 
part  of  the  gut  (Author).*  Such  coils  will,  therefore, 
include  5  feet  of  the  intestine,  and  the  mesentery  here 
nn\  reach  the  length  of  10  inches.  These  coils  are  apt 
to  bang  in  the  pelvis,  and  may  be  easily  herniated.  The 
length  of  the  mesentery  plays  an  important  part  in 
hernia.  If  the  fresh  body  of  an  adult  be  opened,  and 
the  condition  of  the  viscera  and  peritoneum  be  normal, 
it  will  be  found  that  it  is  impossible  to  drag  a  loop  of 
small  intestine  through  the  femoral  canal  (artificially 
enlarged)  on  to  the  thigh,  or  down  the  inguinal  canal 
into  the  scrotum.  In  fact,  no  coil  can,  in  any  part, 
be  drawn  out  of  the  abdomen  below  a  horizontal  line 
on  a  level  with  the  spine  of  the  pubes.  It  is  evident, 
therefore,  that  in  femoral  or  scrotal  hernia  the  mesen- 
tery must  be  elongated  or  its  attachments  lowered. 

*  Scr  "  The  Anatomy  of  the  Intestinal  Canal  and  Peritoneum 
in  Man,"  by  the  Author.     London,  1885. 


320  Surgical  Applied  Anatomy.  [Chap.  xvii. 

The  mesentery  is  relatively  longest  in  infancy  and 
childhood,  and  a  freer  escape  of  the  intestines  from 
the  abdomen  is  allowed  in  subjects  under  puberty. 
The  disposition  of  the  membrane  permits  also  a  freer 
downward  excursion  of  the  bowels  on  the  right  side, 
and  this  has  been  offered  as  an  explanation  of  the  un- 
due frequency  of  right-sided  inguinal  hernia?  in  child- 
hood (Lockwood). 

The  root  of  the  mesentery,  and,  indeed,  the  whole 
of  the  peritoneum  covering  the  posterior  abdominal 
wall,  may  glide  a  little  downwards  and  constitute  a 
"  prolapse  of  the  mesentery."  This  condition  has  been 
fully  investigated  by  Mr.  Lockwood,  who  states  that 
it  seldom  occurs  before  middle  age,  that  it  causes  the 
mass  of  the  intestines  to  incline  to  the  left  and  thus 
encourages  double  and  left-sided  hernia?.  These  hernia? 
are  well  known  to  be  more  common  after  middle 
age. 

Mr.  Lockwood  states  that  in  acquired  hernia  the 
mesentery  is  found  to  have  had  its  attachments  lowered 
rather  than  to  have  been  increased  in  length. 

Certain  holes  are  sometimes  found  in  the  mesentery, 
through  which  intestine  has  been  strangulated.  Some 
of  these  holes,  especially  those  that  are  slit-like,  are 
due  to  injury,  others  are  due  to  congenital  defect  of 
the  mesentery.  I  have  shown  that  the  latter  holes 
are  round,  are  in  the  mesentery  of  the  lower  ileum, 
and  occupy  an  oval  area,  circumscribed  by  an  anasto- 
motic arch  between  the  ileo-colic  branch  of  the  superior, 
mesenteric  artery  and  the  last  of  the  intestinal  arteries. 
This  area  is  often  the  seat  of  atrophied  peritoneum, 
and  shows  an  absence  of  fat,  of  visible  blood-vessels, 
and  of  glands.  It  would  be  easy  for  a  knuckle  of  gut 
to  be  forced  through  the  thinned  membrane,  which  is 
sometimes  already  cribriform. 

For  an  account  of  "  mesenteric  hernia,"  see  page  334. 

Hernia?  have  occurred  through  the  foramen  of 
Winslow. 

I  have  described  a  strangulated  hernia  in  this  position 
which  was  exposed  by  operation. 


Chap,  xvii.]      The  A bdomina l    Viscer a.  321 

The  Stomach. 

Above. 

Liver,  small  omentum,  diaphragm. 


In  front. 

(From    left    to   right) 

diaphragm,  abdominal 

wall,  liver. 


Stomach. 


Behind. 
Transverse  meso-colon, 
pancreas,  crura,  solar 
plexus,  great  vessels, 
spleen,  left  kidney, 
and  capsule. 

Below. 
Great  omentum,  transverse  colon,  gastro-splenic  omentum. 

When  empty,  the  stomach  lies  at  the  back  of  the 
abdomen,  beneath  the  liver  and  some  way  from  the 
surface.  When  distended,  the  greater  curvature  is 
elevated  and  carried  forwards,  the  anterior  surface  is 
turned  upwards,  and  the  posterior  downwards  (Fig. 
48,  p.  356).  The  direction  of  the  rotation  depends  upon 
the  fixity  of  the  smaller  curvature.  When  distended, 
the  stomach  is  brought  well  against  the  anterior  belly 
wall,  and  may  occupy  the  whole  of  the  middle  line  as 
far  as  the  navel.  Thus  the  stomach  is  much  more 
exposed  to  injury  when  full  than  when  empty.  The 
cardiac  orifice  is  situate  behind  the  seventh  left  costal 
cartilage,  about  1  inch  from  the  sternum  (Fig.  40). 
The  pylorus,  when  the  viscus  is  empty,  lies  just  to  the 
right  of  the  middle  line,  from  3  to  4  inches  below  the 
sterno-xiphoid  articulation,  on  the  level  of  a  line  drawn 
between  the  bony  ends  of  the  seventh  ribs.  When 
the  stomach  is  distended  the  pylorus  may  be  moved 
nearly  3  inches  to  the  right  (Braune).  The  cardiac 
orifice  is  on  a  level  behind  with  the  ninth  dorsal  spinous 
process,  the  pylorus  with  the  twelfth  dorsal  spine  (Fig. 
41).  A  horizontal  line  drawn  between  the  extreme 
tips  of  the  tenth  costal  cartilages  will  about  correspond 
to  the  lower  border  of  the  non-distended  stomach. 
The  tenth  cartilage  has  a  distinct  tip  and  plays  over 
the  cartilage  of  the  ninth  rib,  producing  under  the 
finger  a  special  crepitus.  The  fundus  of  the  stomach 
occupies  the  left  dome  of  the  diaphragm  and  reaches 
on  the  left  side  as  high  as  the  level  of  the  sixth  sterno- 


322 


Fig.  40.— Diagram  showing  the  Kelations  of  the  Viscera  to  the  Parietes 

(Anterior  view). 

s,  Stomach  ;  l,  liver ;  k,  kidney ;  tc,  transverse  colon ;  os  umbilicus. 


Chap,  xvn.]      The  Abdominal    Viscera.  323 

chondral  articulation,  being  a  little  above  and  behind 
the  heart  apex.  The  close  relations  of  the  stomach 
to  the  diaphragm  and  thoracic  viscera  serve  in  part  to 
explain  the  shortness  of  breath  and  possible  palpitation 
of  the  heart,  etc.,  that  may  follow  upon  distension  of  the 
organ  (Fig.  43,  p.  337).  The  near  proximity  of  the  heart 
to  the  stomach  is  illustrated  by  a  case  where  a  thorn 
(of  the  Prunus  spuwsa),  ^  an  inch  long,  had  been 
swallowed  and  had  then  found  its  way  through  the 
diaphragm  and  pericardium  into  the  wall  and  cavity 
of  the  right  ventricle. 

On  reference  to  the  development  of  the  stomach, 
it  will  be  seen  that  it  is  originally  placed  vertically  in 
the  abdomen.  This  position  may  be  to  a  great  extent 
maintained  in  adult  life.  The  feats  of  an  acrobat  who 
styles  himself  "  the  sword  swallower "  can  hardly  be 
explained  on  any  other  supposition  than  that  his 
stomach  is  vertical ;  but  whether  such  condition  is 
congenital,  or  has  been  produced  by  the  manoeuvre 
he  practises,  must  be  an  open  question. 

Although  the  mobility  of  the  stomach  is  not  con- 
siderable, yet  it  is  frequently  found  to  occupy  both 
diaphragmatic  and  epigastric  hernial  In  the  condition 
known  as  ptosis  of  the  stomach  the  whole  organ  is  dis- 
placed downwards.  The  stomach  is  fixed  to  the  liver 
and  to  the  diaphragm  (round  the  cardiac  orifice)  by 
fcEe  gastro-hepatic  omentum,  and  in  such  cases  of  ptosis 
this  band  is  said  to  be  found  stretched. 

The  viscus  is  susceptible  of  enormous  dilatation 
when  the  pylorus  is  obstructed.  The  distended  organ 
may  reach  as  low  as  Poupart's  ligament. 

The  stomach  rests  behind  on  the  lesser  sac  of  the 
peritoneum,  which  plays  the  part  of  a  bursa  to  it.  Gastric 
ulcers  rarely  perforate  into  the  lesser  sac.  but  when 
they  do  the  contents  can  only  escape  by  the  foramen 
of  Winslow,  and  may  not  be  seen  when  the  abdomen 
is  opened.  The  sac  is  opened  by  perforating  the  great 
omentum  at  the  greater  curvature  of  the  stomach. 

The  Stomach  lias  been  frequently  wounded.  In 
mosl    cases  a   fatal   result   rapidly  follows  upon   these 


324  Surgical  Applied  Anatomy.  [Chap.  xvii. 

injuries,  for  the  contents  of  the  stomach  escape  into 
the  peritoneal  cavity  and  set  up  an  acute  peritonitis. 
The  most  certainly  and  rapidly  fatal  cases,  therefore, 
are  those  in  which  the  stomach  was  full  of  food  at  the 
time  of  the  accident.  The  empty  stomach,  being  deeply 
placed  and  lying  against  the  posterior  abdominal  wall 
in  a  collapsed  state,  is  but  little  exposed  to  injury.  A 
small  punctured  wound  of  the  stomach  need  not  be 
followed  by  escape  of  contents,  since  the  loosely  attached 
mucous  membrane  may  escape  from  the  wound  and 
effectually  plug  it.  This  was  illustrated  many  times 
in  the  Boer  war,  the  viscus  having  been  perforated  by 
a  Mauser  bullet.  The  stomach  has  protruded  through 
wounds  in  the  abdominal  walls,  and  has  been  returned, 
with  no  evil  results  following.  In  a  few  cases  the  belly 
wall  in  front  of  the  stomach  has  been  wounded,  the 
viscus  has  protruded,  its  anterior  wall  has  been  wounded 
by  the  same  injury  that  penetrated  the  parietes,  and  a 
fistulous  opening  leading  into  the  stomach  cavity  has 
resulted.  The  best  example  of  such  cases  is  afforded 
by  the  well-known  instance  of  Alexis  St.  Martin,  the 
subject  of  so  many  physiological  experiments.  In  this 
man  the  abdominal  parietes  in  front  of  the  stomach 
were  torn  away  by  a  gunshot  wound,  a  part  of  the 
anterior  wall  of  the  stomach  sloughed,  and  a  permanent 
fistula  resulted.  Dr.  Murchison  reports  the  case  of  a 
woman  in  whom  a  gastric  fistula  was  produced  by 
the  continued  pressure  of  a  copper  coin  worn  over  the 
epigastric  region.  This  coin  was  deliberately  worn  by 
the  patient  in  order  to  excite  a  lesion  that  would  arouse 
the  sympathy  of  her  friends.  The  pressure  led  to  an 
ulceration  that  finally  opened  up  the  stomach.  In 
many  cases  the  fistula  has  been  due  to  ulcerative  diseases 
commencing  in  the  stomach  itself  and  spreading 
outwards. 

Some  remarkable  cases  have  been  recorded  where 
foreign  substances  have  been  swallowed  and  have  lodged 
in  the  stomach.  Certain  of  these  cases  serve  to  illustrate 
the  capacity  of  the  stomach,  and  among  the  most 
striking  is  an  instance  where  the  viscus  at  death  was 


325 


ITig    41.— Diagram  to  show  the  Eelations  of  the  Viscera  to  the  Parietes 

(Posterior  view). 

s,  Stomach;  L,  liver;  K,  kidney;  sp,  spleen;  B,  rectum. 


326  Surgical  Applied  Anatomy.  [Chap. xvn. 

found  to  contain  thirty-one  entire  spoon-handles,  each 
about  5  inches  long,  four  half-handles,  nine  nails,  half 
an  iron  shoe-heel,  a  screw,  a  button,  and  four  pebbles. 
The  whole  mass  weighed  2  lb.  S  oz.  The  patient  was 
a  lunatic.  The  pyloi'us  has  an  average  diameter  of 
16  mm.  This  about  corresponds  to  the  diameter  of 
a  sixpenny-piece.  It  is  normally  in  a  closed  state,  and 
should  be  capable  of  taking  the  fore-finger  when  open. 
In  spite  of  the  narrowness  of  the  pylorus,  large  sub- 
stances that  have  been  swallowed  have  been  passed 
by  the  anus  without  trouble.  Among  these  may  be 
noted  a  metal  pencil-case  4|-  inches  long,  10  ounces  of 
garden  nails,  and  fragments  of  crockery-ware  swallowed 
by  a  lunatic  ;  a  fork,  a  door-key,  and  other  strange 
bodies.  Needles  and  similar  sharp  substances  that 
have  been  swallowed  have  travelled  out  of  the  stomach 
or  bowels  and  have  found  their  way  to  the  surface  at 
various  points  in  the  body.  In  a  patient  under  my 
care  at  the  London  Hospital  I  extracted  from  beneath 
the  skin,  near  the  groin,  a  needle  swallowed  some 
months  previously.  In  a  case  reported  in  the  Lancet 
a  needle  was  extracted  from  the  middle  of  the  thigh 
six  months  after  it  had  been  swallowed,  and  like  instances 
are  recorded  elsewhere. 

The  lymphatics  of  the  stomach  pass  mostly  to  the 
glands  situated  between  the  layers  of  the  small  omentum 
along  the  lesser  curvature  of  the  stomach.  Some  also 
pass  to  the  glands  scattered  along  the  greater  curvature 
of  the  stomach.  In  cancer  of  the  pylorus,  the  glands 
along  the  lesser  curvature  are  the  first  to  become  affected, 
and  from  these  the  disease  spreads  to  the  cceliac  glands 
near  the  commencement  of  the  thoracic  duct.  Owing 
to  a  free  communication  between  the  lymphatics  of 
the  pylorus,  pancreas,  and  liver,  the  disease  frequently 
involves  these  organs. 

Gastrotomy  and  gastrostomy. — Gastrotomy 
consists  in  opening  the  stomach  through  the  anterior 
abdominal  wall  for  the  purpose  of  removing  a  foreign 
body,  for  making  an  examination,  or  for  dealing  with  a 
simple  or  malignant  ulcer ;  gastrostomy,  in  opening  the 


chap,  xvii.]      The  Abdominal    Viscera.  327 

stomach  in  a  like  situation  with  the  object  of  establishing 

a  gastric  fistula  through  which  the  patient  may  be  fed 
in  cases  where  the  gullet  is  occluded  by  disease.  The  un- 
covered part  of  the  stomach,  accessible  in  these  opera- 
tions, is  represented  by  a  triangular  area,  bounded  on 
the  right  by  the  edge  of  the  liver,  on  the  left  by  the 
cartilages  of  the  eighth  and  ninth  ribs,  and  below  by  a 
horizontal  line  passing  between  the  tips  of  the  tenth 
costal  cartilages  (Fig.  40).  In  the  empty  condition  five- 
sixths  of  the  stomach  lies  beneath  the  left  hypochondriac 
region,  only  part  of  the  pyloric  end  being  exposed  in  the 
triangular  area.  The  incision  in  these  operations  must 
be  situate  in  this  triangle,  and  may  be  made  either  parallel 
to,  and  about  two  fingers1  breadths  from,  the  free  border 
of  the  costal,  or  along  the  left  semilunar  line.  In  the 
former  incision  the  three  flat  muscles  of  the  abdomen  are 
cut  through.  In  gastrostomy  the  stomach  is  not  opened 
at  the  time  of  the  operation,  but  is  merely  secured  to  the 
wound,  and  a  few  days  are  then  allowed  to  elapse  so  that 
adhesions  may  form.  At  the  end  of  this  time  the  viscus 
is  opened.     The  opening  must  needs  be  very  small. 

Resection  of  the  pylorus. — The  pylorus  is 
frequently  the  seat  of  cancer.  As  a  means  of  relieving 
the  patient,  the  whole  of  the  diseased  pylorus  has  been 
removed,  and  the  divided  ends  of  the  stomach  and 
duodenum  united  by  sutures.  The  situation  of  the  can- 
cerous pylorus  within  the  abdomen  varies  considerably, 
as  the  diseased  part  is  very  apt  to  shift  its  position.  It 
is  often  found  to  have  sunk  down  by  its  weight  to  a 
point  below  the  umbilicus,  and  to  have  contracted 
adhesions  to  adjacent  organs.  The  diseased  part  has 
to  be  isolated  and  the  omental  connections  of  the  right 
end  of  the  stomach  freely  divided.  The  vessels  that 
are  almost  certainly  divided  are  the  pyloric,  the  gastro- 
epiploica  dextra,  and  the  gastro-duodenal.  The  opera- 
tion has  not  been  attended  with  much  success.  The 
cancer  is  apt  to  become  diffuse,  to  spread  to  adjacent 
tissues,  and  to  lead  to  early  lymphatic  invasion  of  the 
greater  and  lesser  omenta. 

Gastrectomy.  —  Considerable    portions    of    the 


328  Surgical  Applied  Anatomy.  [Chap. xvii. 

stomach  have  been  excised  in  cases  of  cancer,  and  the 
entire  organ  has  been  removed  (total  gastrectomy) 
for  the  same  cause.  Up  to  the  time  of  writing  some 
fifteen  examples  of  this  operation  have  been  recorded 
with  more  or  less  immediate  death  in  five.  Schlatter's 
original  case  of  gastrectomy,  performed  in  1897,  died 
in  fourteen  months  from  secondary  deposits.  Eicord 
published  a  case  in  which  he  removed  the  whole  stomach, 
the  first  piece  of  the  duodenum,  and  part  of  the  pan- 
creas. The  patient  was  alive  and  well  eleven  months 
after  the  operation  (Gaz.  des  Hopitaux,  March  22nd, 
1900).  It  has  yet  to  be  shown  that  the  operation  is  of 
genuine  value.  There  is  difficulty  in  uniting  the  gullet 
to  the  small  intestine ;  both  vagi  nerves  are  divided 
as  they  emerge  through  the  diaphragm,  and  the  solar 
flexus  is  apt  to  be  roughly  handled  ;  the  operation  is  an 
extreme  test  for  a  weakened  patient,  and  the  after  con- 
ditions of  those  who  survive  is  not  free  from  distress. 
There  is,  however,  less  disturbance  of  digestion  than 
would  be  imagined. 

Other  operations  on  the  stomach. — 
Many  other  operations  are  performed  upon  the 
stomach  which  call  merely  for  mention  in  this  place. 
One  of  the  most  useful  and  the  most  frequently  per- 
formed is  gastroenterostomy.  Here  an  opening  (or 
stoma)  is  made  between  the  stomach  and  the  upper 
part  of  the  jejunum.  The  operation  is  performed  in 
cases  of  stenosis  of  the  pylorus,  in  cases  of  dilatation 
of  the  stomach  without  much  stenosis,  in  certain  ex- 
amples of  ulcer,  and  in  many  other  conditions.  In  the 
operation  of  pyloroplasty,  a  non-malignant  stricture  of 
the  pylorus  is  divided  and  the  pyloric  passage  thus  made 
free.  In  gastroplication  certain  conditions  of  dilated 
stomach  are  dealt  with  by  taking  in  a  fold  or  pleat  in 
the  stomach  wall  and  in  thus  lessening  its  capacity. 

The  small  intestines.* — The  average  length  of 
the  small  intestine  in  the  adult  is  22j  feet,  the  ex- 

*  The  account  of  the  intestines  is  derived  from  the  Author's 
work  "On  the  Intestinal  Canal  and  Peritoneum  in  Man." 
London.     1885. 


chap,  xvii.]      The  Abdominal   Viscera.  329 

tremes  being  30  feet  and  15  feet.  In  the  fcetus,  at 
full  term,  the  lesser  bowel  measures  about  9^  feet.  It 
is  roughly  reckoned  that  the  first  8  or  9  feet  of  the 
adult  bowel  belongs  to  the  jejunum,  and  the  remaining 
12  or  13  feet  to  the  ileum. 

The  division  into  jejunum  and  ileum  is  quite  arbi- 
trary. There  is  no  one  point  where  it  can  be  said 
that  the  jejunum  ends  and  the  ileum  commences. 
When  the  small  intestines  are  exposed  by  accident  or 
operation,  it  is  often  difficult,  especially  when  there 
is  abdominal  disease,  to  recognise  the  upper  from  the 
lower  part  of  the  gut.  It  may  be  noted,  however, 
that  the  jejunum  is  wider  than  the  ileum  (its  diameter 
being  \  of  an  inch  greater  than  that  of  the  ileum), 
and  its  coats  are  thicker  and  more  vascular.  If  the  gut 
be  empty,  and  can  be  rendered  translucent  by  being  held 
against  a  light,  the  lines  of  the  valvuhe  conniventes 
can  be  well  seen.  These  folds  are  large  and  numerous 
in  the  jejunum,  but  become  small  and  scanty  in  the 
upper  ileum,  and  are  wanting  in  the  lower  third  of  that 
bowel.  Injuries  to  the  jejunum  are  more  serious  than 
are  those  of  the  ileum,  since  an  intestinal  lesion  is  (other 
things  being  equal)  the  more  serious  the  nearer  it 
approaches  to  the  stomach.  The  fatality  of  umbilical 
hernise  probably  depends  in  part  upon  the  fact  that  the 
contained  bowel  is  often  jejunum.  The  coils  of  small 
intestine  occupy  no  certain  position  in  the  abdomen. 
In  the  fcetus,  and  during  the  earliest  part  of  extra- 
uterine life,  the  bulk  of  the  small  intestine  is  placed  to 
the  left  of  the  middle  line.  This  is  on  account  of  the 
relatively  large  size  of  the  liver,  to  the  weight  of  which 
the  lesser  bowel  no  doubt  acts  as  a  counterpoise.  In 
the  majority  of  adult  bodies  the  small  intestine  is  dis- 
posed in  an  irregularly  curved  manner  from  left  to  right. 
The  gut,  starting  from  the  duodenum,  will  first  occupy 
the  contiguous  parts  of  the  left  side  of  the  epigastric 
and  umbilical  regions  ;  the  coils  then  fill  some  part  of 
the  left  hypochondriac  and  lumbar  regions  ;  they  now 
commonly  descend  into  the  pelvis,  re-appear  in  the  left 
iliac  quarter,  and  then  occupy  in  order  the  hypogastric, 


33©  Surgical  Applied  Anatomy.  [Chap.  xvii. 

lower  umbilical,  right  lumbar,  and  right  iliac  regions. 
Before  reaching  the  latter  situation  they  commonly 
descend  again  into  the  pelvis. 

Much  interest  attaches  to  the  coils  of  small  in- 
testine that  are  found  in  the  pelvis.  These  are  the 
coils  that  are  apt  to  become  involved  and  adherent  in 
cases  of  pelvic  peritonitis,  and  that  would  probably 
form  the  protrusion  in  most  cases  of  obturator,  sciatica, 
and  pudendal  hernia.  No  small  intestine  occupies  the 
foetal  pelvis.  The  amount  found  in  the  adult  pelvis 
depends  mainly  upon  the  state  of  distension  of  the 
bladder  and  rectum,  and  upon  the  position  of  the 
sigmoid  flexure.  The  coils  that  are  most  usually  found 
in  this  position  belong  to  the  terminal  part  of  the  ileum, 
and  to  that  part  of  the  intestine  that  has  been  already 
alluded  to  as  possessing  the  longest  mesentery  (page  319). 
The  ileum  is  the  part  of  the  intestine  that  is  most  fre- 
quently found  in  inguinal  and  femoral  hernias.  It  is 
also  the  part  most  usually  involved  in  cases  of  strangula- 
tion by  internal  bands,  by  holes  in  the  mesentery,  etc. 

Of  all  the  viscera  the  small  intestines  are  the  most 
exposed  to  injury,  and  at  the  same  time  it  must  be 
noted  that  by  their  elasticity,  and  by  the  ease  with 
which  their  coils  slide  over  one  another  and  so  elude 
the  effects  of  pressure,  they  are  the  best  adapted  to 
meet  such  injuries  as  contusions  and  the  like.  A  minute 
punctured  wound  of  the  small  gut  does  not  lead  to 
extravasation  of  contents.  The  muscular  coat  contracts 
and  closes  the  little  opening.  Thus,  in  excessive  tym- 
panitis the  bowels  are  often  freely  punctured  in  many 
places  with  a  fine  capillary  trochar,  to  allow  the  gas  to 
escape,  without  any  evil  resulting.  A  case  of  intestinal 
obstruction  of  sixteen  weeks'  duration  is  reported,  in 
which  the  abdomen  was  punctured  150  times  (Boston 
Med.  Journ.).  If  the  wound  be  a  little  larger  the  loose 
mucous  membrane  becomes  everted  or  protruded 
through  the  wound  and  effectually  plugs  it.  Gross 
found  that  a  longitudinal  cut  in  the  small  bowel  2|- 
lines  in  length  was  immediately  reduced  to  a  wound 
If  lines  in  length  by  muscular  contraction,  and  that  the 


Chap,  xvii.]      The  Abdominal    Viscera.  331 

eversion  of  the  mucous  membrane  in  addition  to  this 
contraction  entirely  sealed  the  opening.  Even  the 
opening  made  in  the  intestine — for  example,  in  the 
jejunum — by  the  penetration  of  a  Mauser  bullet  may  be 
attended  by  no  escape  of  contents.  A  contracted  empty 
piece  of  bowel  becomes  nearly  twice  as  long  when 
distended. 

Owing  to  the  greater  power  of  the  circular  layer 
of  muscle  a  longitudinal  wound  gapes  more  than  a 
transverse  wound,  and,  in  consequence  of  the  greater 
muscular  development  of  the  jejunum,  wounds  of  that 
part  gape  more  than  do  those  of  the  ileum.  Trans- 
verse wounds  gape  most  when  inflicted  across  the  free 
border  of  the  gut,  since  in  that  place  the  longitudinal 
muscular  fibres  are  thickest. 

In  one  remarkable  case  a  man  was  stabbed  in  the 
belly.  It  was  subsequently  found  that  there  was  a 
small  puncture  in  the  ileum,  which  had  been  plugged 
by  the  mucous  membrane  and  further  secured  by 
recent  lymph.  The  man  did  well  until  the  fourth 
day,  when  he  died  somewhat  suddenly.  It  was  then 
found  that  an  intestinal  worm  (Ascaris  lumbricoides) 
had  worked  its  way  through  the  wound,  breaking 
down  the  adhesions,  and  had  escaped  into  the  peri- 
toneal cavity.  Extravasation  followed,  and  thus  the 
worm  was  the  immediate  cause  of  the  man's  death. 

The  calibre  of  any  portion  of  the  small  intestine 
depends  mainly  upon  the  condition  of  its  muscular  wall. 
The  tube  may  become  much  contracted  when  empty. 
In  peritonitis  and  in  certain  other  conditions  the  muscular 
coat  is  paralysed  and  the  bowel  becomes  intensely  dilated 
by  gas  (tympanitis). 

Meckel's  diverticulum. — From  one  to  four 
feet  from  the  end  of  the  ileum  is  sometimes  seen  a 
diverticulum  (Meckel's)  that  represents  the  remains  of 
the  vitello-intestinal  duct  (page  289).  It  may  be  expected 
in  2  per  cent,  of  the  bodies  examined.  This  diverti- 
culum usually  exists  as  a  tube  of  the  same  structure 
as  the  intestine.  Its  length  varies.  It  may  sometimes 
extend  as  a  patent  tube  as  far  as  the  umbilicus.     It 


332  Surgical  Applied  Anatomy.  [Chap.  xvn. 

is  more  often  but  a  few  inches  long,  and  may  then  end 
in  a  free  conical  or  globular  extremity,  or  in  a  fibrous 
cord.  This  diverticulum  may  cause  intestinal  obstruc- 
tion in  many  ways.  Its  end  may  contract  adhesions, 
and  beneath  the  bridge  thus  formed  a  loop  of  bowel 
may  be  strangled.  It  may  twist  itself  about  a  piece  of 
intestine  so  as  to  form  a  knot  round  it.  It  may,  from 
its  adhesions,  so  drag  upon  the  ileum  as  to  cause 
"  kinking  "  of  the  tube  at  its  point  of  origin.  In  more 
than  one  case  it  has  been  found  in  an  external  hernia. 
It  may  become  invaginated  and  start  an  intussusception 
of  the  bowel. 

The  duodenum  and  fossa  duodeno- 
Jejunalis. — The  first  portion  of  the  duodenum  is 
nearly  horizontal.  It  measures  about  2  inches  in 
length  and  passes  backwards  from  the  pylorus  to  near 
the  upper  end  of  the  right  kidney.  The  second 
portion,  about  3  inches  in  length,  descends  vertically 
in  front  of  the  inner  border  of  the  right  kidney  to  the 
level  of  the  third  lumbar  vertebra.  The  third  portion, 
some  5  inches  in  length,  crosses  from  right  to  left  in  front 
of  the  third  vertebra,  and  then  ascends  for  a  short 
distance  on  the  surface  of  the  left  psoas  muscle,  to  end 
in  the  jejunum  to  the  left  of  the  second  lumbar  vertebra. 
The  first  portion,  which  is  movable,  is  invested  by  peri- 
toneum, in  the  same  manner  as  the  stomach.  The 
second  part  is  covered  by  peritoneum  in  front  only, 
except  at  the  spot  where  it  is  crossed  by  the  trans- 
verse colon.  The  third  part  is  also  covered  by  peri- 
toneum only  on  its  anterior  aspect,  this  membrane  being, 
however,  free  of  the  gut  where  the  superior  mesenteric 
vessels  cross  it. 

The  first  portion  has  found  its  way  into  hernise  in 
company  with  the  stomach,  but  the  second  and  third 
parts  are  never  herniated.  The  end  of  the  duodenum, 
the  duodeno-jejunal  bend,  is  very  firmly  held  in  place 
by  a  band  of  fibrous  tissue  that  descends  upon  it  from 
the  left  crus  of  the  diaphragm  and  the  tissue  about 
the  cceliac  axis.  This  band  is  called  the  suspensory 
muscle  of  the  duodenum  (Treitz).       It  serves  also  to 


Chap,  xvii.]      The  Abdominal    Viscera.  333 

support  the  mesentery.  No  matter  to  what  extent 
the  stomach  may  be  displaced  by  distension,  or  the 
intestines  disturbed  by  a  like  cause,  the  position  of  the 
duodeno-jejunal  bend  will  be  found  to  remain  unaltered. 
All  sections  of  the  duodenum  have  been  ruptured  by 
violence.  Owing  to  its  large  non-peritoneal  surface, 
the  bowel,  if  approached  from  behind,  may  be  wounded 
without  opening  the  peritoneum  (Fig.  47,  p.  353). 

In  connection  with  the  spread  of  disease  by  con- 
tinuity of  tissue,  it  is  w^ell  to  note  that  the  duodenum 
is  in  relation  with  the  liver,  gall  bladder,  pancreas, 
transverse  colon,  spine,  right  kidney,  bile  duct,  portal 
vein,  gastro-duodenal  and  superior  mesenteric  vessels, 
aorta  and  vena  cava. 

In  the  duodenum  are  Brunner's  glands,  which  are 
sometimes  the  seat  of  a  perforating  ulcer  in  cases  of 
burns.  They  are  mostly  seated  in  the  first  segment 
of  this  bowel,  and  the  perforation,  therefore,  usually 
opens  into  the  peritoneal  cavity.  A  diverticulum  is 
sometimes  present.  The  liver  and  pancreas  are  both  de- 
veloped as  epithelial  buds  from  the  duodenal  part  of 
the  canal  in  the  embryo.  Congenital  strictures  of  the 
intestine  are  not  uncommonly  placed  in  the  duodenum. 

The  peculiar  vertical  curve  of  the  duodenum  closely 
resembles  that  of  the  syphon  trap  used  in  drains.  Mr. 
Mayo  Collier  has  pointed  out  that  this  part  of  the  bowel 
probably  acts  as  a  real  syphon  trap,  and  so  prevents 
the  regurgitation  of  intestinal  gas  into  the  stomach. 
The  duodenum  of  the  horse  appears  to  act  also  in  this 
manner. 

Passing  from  the  front  of  the  terminal  (ascending) 
part  of  the  duodenum,  a  fold  of  peritoneum  is  often  seen, 
that  joins  the  parietal  peritoneum  to  the  left  of  the  piece 
of  gut  in  question.  This  fold  marks  off  a  fossa  of  tri- 
angular outline,  the  orifice  of  which  is  directed  upwards. 
I  have  found  the  fossa  in  about  50  per  cent,  of  the  bodies 
examined.  It  is  called  the  fossa  duodciio-je  jimalis ; 
it  is  usually  large  enough  to  lodge  the  tip  of  the  finger, 
and  its  opening  lies  just  below  the  duodeno-jejunal  bend 
(Fig.  42).     This  fossa  is  the  anatomical  cause  of  mesen- 


334 


Surgical  Applied  Anatomy.  [Chap.  xvii. 


teric,  meso-colic,  meso-gasti'ic,  or  retro-peritoneal  hernia. 
The  commencement  of  the  jejunum  presses  into  the 
fossa,  enlarges  its  cavity,  and  ultimately  separates  the 
peritoneum  from  its  posterior  attachments.  More 
and  more  of  the  small  intestine  passes  into  the  increasing 
pouch,  until  at  last,  as  in  the  case  reported  by  Sir  Astley 
Cooper  and  many  others,  nearly  the  whole  of  the  small 
intestine  may  be  found  lodged  in  an  enormous  median 
retro-peritoneal  sac,  the  mouth  of  which  is  the  orifice 


Fig.  42. — The  Fossa  Duodeno-jejunalis  (Treves). 

of  the  fossa  duodeno-jejunalis.  The  duodenum  can  be 
seen  to  enter  the  sac  and  the  end  of  the  ileum  to  leave 
it.  The  sac  usually  extends  downwards  on  the  left 
side,  and  may  reach  the  promontory  of  the  sacrum. 
These  hernise  vary  in  size,  but  are  as  a  rule  large.  The 
ccecum  and  ascending  colon  have  their  normal  position, 
but  the  transverse'  and  descending  parts  of  the  colon 
are  stretched  over  and  displaced  by  the  sac.  The  renal 
artery  is  behind  the  hernia,  and  the  inferior  mesenteric 
artery  is  in  front  of  it  and  to  the  left.     A  branch  of  this 


chap,  xvn.]      The  Abdomixal    Viscera.  335 

vessel,  the  colica  sinistra,  is  near  to  the  orifice  of  the 
sac  in  its  lower  part. 

Operations  011  the  small  intestine. — Entcr- 
otomy  is  the  operation  of  opening  the  small  intestine 
above  some  obstruction  that  threatens  to  be  fatal  or  in- 
superable. The  incision  is  made  in  the  linea  alba,  below 
the  umbilicus,  or  in  one  or  other  iliac  region,  as  is  con- 
sidered more  convenient.  An  incision  some  2  or  3  inches 
in  length  will  probably  suffice.  The  peritoneum  having 
been  opened,  a  knuckle  of  small  bowel  close  above  the 
obstruction  is  seized,  is  secured  to  the  parietal  wound, 
and  then  opened.  The  small  intestine  has  also  been 
opened  to  remove  impacted  foreign  bodies  and  large 
gall  stones.  In  such  cases  the  intestinal  wound  is 
usually  closed  immediately.  Enterectomy. — Portions  of 
the  small  intestine  have  been  resected  with  success  for 
various  diseased  conditions.  In  one  case  more  than 
two  yards  of  the  small  intestine  were  cut  away  on  account 
of  multiple  stricture.  The  patient,  a  young  woman, 
made  an  excellent  recovery.  Resections  have  also 
been  successfully  performed  in  cases  of  bullet  wound 
or  stab  involving  the  lesser  bowel,  and  in  other  injuries. 
Tumours  of  the  gut  have  been  removed  by  a  partial 
resection.  Non-malignant  strictures  of  the  bowel  have 
been  treated  by  incision  and  dilatation. 

The  bowel  above  an  obstruction  has  been  connected 
to  the  bowel  below  an  obstruction  by  the  operation 
called  intestinal  anastomosis  or  short  circuiting. 

In  uniting  divided  intestine  by  suture  (enteroraphy) 
it  is  essential  that  the  serous  coat  of  the  ends  of  the 
bowel  should  be  brought  together.  This  is  best  effected 
by  the  suture  known  as  Lembert's,  with  the  addition 
of  a  special  and  separate  line  of  sutures  for  the  mucous 
membrane.  Experience  shows  that  if  leakage  occurs 
after  resection  or  suture  of  intestine  it  will  most  likely 
occur  along  the  attachment  of  the  mesentery.  This 
circumstance  is  thus  explained  by  Mr.  Anderson.  The 
two  layers  of  the  mesentery  diverge  as  they  approach 
the  bowel,  and  so  leave  a  triangular  space,  the  base 
of  which,  averaging  about  Aths  of  an  inch  in  width 


336  Surgical  Applied  Anatomy.  [Chap.  xvn. 

is  formed  by  the  uncovered  muscular  tissue.  It  is  the 
existence  of  this  bare  piece  of  intestine  that  renders 
adjustment  of  the  serous  coat  at  the  attachment  of  the 
mesentery  a  matter  of  some  difficulty. 

The  ileo-csecal  region. — The  caecum  is,  to  a 
certain  extent,  rudimentary  in  man,  as  it  is  also  in 
the  carnivora.  In  herbivorous  animals  it  is  of  great 
size,  and  appears  to  serve  as  a  reservoir  for  the  elabor- 
ation and  absorption  of  food.  It  has  been  said  that 
the  caecum  in  man  exists  as  an  anatomical  protest 
against  vegetarianism.  The  appendix  persists  as  the 
remains  of  the  larger  ceecum  of  lower  mammals.  In 
the  human  foetus  it  can  be  seen  to  be  but  the  narrowed 
extremity  of  a  capacious  ceecum.  The  foetal  type  of 
ceecum,  which  is  very  characteristic,  may  persist 
throughout  life.  From  the  point  of  view  of  evolution 
the  appendix  would  appear  to  be  becoming  obliterated. 
Like  other  functionless  parts  that  persist  as  develop- 
mental relics,  it  is  very  frequently  the  seat  of  disease, 
and  it  is  worthy  of  note  that  such  disease  tends  to  cause 
the  entire  obliteration  of  the  part  (as  after  many  forms 
of  so-called  appendicitis). 

It  must  be  understood  that  the  term  caecum  is  applied 
to  that  part  of  the  colon  that  lies  below  the  entrance 
of  the  ileum.  The  average  breadth  of  the  adult  ceecum 
is  3  inches,  its  average  length  (vertical  measurement) 
2  \  inches. 

The  ceecum  is  usually  lodged  in  the  right  iliac  fossa, 
and  is  so  placed  that  its  apex  corresponds  with  a  point 
a  little  to  the  inner  side  of  the  middle  of  Pou part's  liga- 
ment. When  distended  with  gas  or  feecal  contents 
it  occupies  the  whole  of  the  right  iliac  fossa.  A  point 
1^  inches  above  and  internal  to  the  anterior  superior 
iliac  spine  lies  over  the  ileo-ceecal  valve. 

A  slightly  distended  ceecum  so  located  may  be 
emptied  by  flexing  the  thigh  upon  the  abdomen.  The 
ceecum  is  always  entirely  invested  by  peritoneum.  Its 
posterior  surface  is  never  in  connection  with  the  areolar 
tissue  of  the  iliac  fossa  (Fig.  43).  The  peritoneum 
is  reflected  from  the  commencement  of  the  ascending 


chap,  xvii.]     The  Abdominal   Viscera. 


337 


colon  on  to  the  posterior  parietes  below  the  level  of 
the  iliac  crest,  A  mobile  caecum  may  hang  over 
the  pelvic  brim,  or  occupy  the  pelvis,  or  even  find  its 
way  into  an  inguinal  hernia  of  the  left  side. 

The  caecum  is  not  infrequently  found  in  an 
inguinal  or  femoral  hernia  of  the  right  side  (caecal 
hernia).  Such  hernia?  are,  except  in  a  few  rare 
instances,  provided  with  a  proper  and  complete 
peritoneal  sac. 

Foreign     bodies    that    have    been    swallowed  'are 


ME5C  COLON 


ILEO-COUC  FOSSA 


BLOODLESS  FOLD 


RE.TRO-CAECAL  FOSSA 

ILEO-CAECAL  FOSSA 

Fig.  43.— The  peritoneal  fossae  of  the  ileo-csecal  region. 

very  apt  to  lodge  in  the  caecum,  and  in  that  situation 
may  cause  ulceration  and  even  perforation  of  the 
bowel,  producing  one  form  of  typhlitis. 

In  cases  of  faecal  retention,  also,  the  largest  accumula- 
tion of  faecal  matter  is  very  usually  met  with  in  the 
caecum,  and  upon  that  part  of  the  1  towel  when  distension 
is  extreme  the  greatest  strain  usually  comes. 

Stercoral  ulcers  (ulcers  due  to  the  pressure  and 
irritation  of  retained  fasces)  are  more  often  met  with 
in  the  caecum  than  in  any  other  part  of  the  colon. 
Solitary  follicles  are  numerous  in  the  mucous  membrane 
of  the  caecum.  Intestinal  concretions  also  are  not 
uncommon  in  this  part. 

The  caecum  is  susceptible  of  enormous  distension, 

w 


3$S  Surgical  Applied  Anatomy.  [Chaj>.  xvil. 

provided  that  it  be  gradually  effected,  and,  in  certain 
instances,  a  dilated  caecum  has  been  found  to  occupy 
a  large  part  of  the  abdominal  cavity.  When  the  abdo- 
men is  opened  in  any  doubtful  case  of  intestinal  obstruc- 
tion, the  condition  of  the  caecum  is  of  great  value  in 
pointing  to  the  seat  of  the  obstacle.  In  stenosis  of  the 
colon  it  will  be  found  greatly  distended,  while  in 
obstruction  of  the  small  gut  it  will  be  empty,  or,  at 
least,  in  a  normal  condition. 

The  appendix  varies  in  length.  Its  average 
measurement  in  the  adult  is  4  inches,  the  extremes  being 
1  inch  and  6  inches.  Its  position  varies,  although,  as  a 
rule,  it  is  seen  to  lie  behind  the  end  of  the  ileum  and 
its  mesentery,  and  to  point  in  the  direction  of  the  spleen. 
It  frequently  also  lies  behind  the  caecum.  I  have  seen 
the  appendix  so  placed  with  reference  to  the  bowel 
that  it  would  have  been  encountered  in  a  right  lumbar 
colotomy.  In  such  cases  the  appendix  has  been  pushed 
behind  the  caecum  and  caught  in  the  meso-colon  during 
the  later  months  of  foetal  life,  when  the  colon  migrates 
from  the  neighbourhood  of  the  liver  to  the  right  iliac 
fossa.  The  appendix  may  hang  within  the  pelvis  and, 
in  inflammatory  conditions,  contract  adhesions  to  the 
ovary  or  other  pelvic  structures.  I  have  found  an 
inflamed  appendix  adherent  to  the  liver  and  another 
in  the  left  iliac  fossa.  It  has  found  its  way  down  both 
the  right  and  the  left  inguinal  canals. 

The  tip  of  the  process  may  adhere  to  a  neighbouring 
peritoneal  surface,  and  thus  form  a  "  band,"  beneath 
which  a  piece  of  small  intestine  may  be  strangulated. 

Foreign  bodies  occasionally  lodge  in  the  appendix, 
and  it  is  very  often  found  to  be  occupied  by  a  faecal 
concretion  or  calculus.  These  substances  excite  inflam- 
mation, and,  as  a  result,  the  appendix  may  become 
perforated.  Troubles  in  the  vermiform  process  are  the 
most  frequent  causes  of  perityphlitis,  a  term  applied  to 
localised  inflammation  of  the  peritoneum  in  the  vicinity 
of  the  caecum. 

From  the  position  of  the  appendix  it  will  be  under- 
stood' how  it  has  happened  that  inflammation  of  the 


Chap.  Xvii.r     The  Abdominal   Viscera.  339 

organ,  has  been  mistaken  for  ovaritis,  for  peri-renal 
inflammation,  or  even  for  hip  disease.  In  appendicitis 
there  is  often  pain  down  the  right  thigh  and  stiffness  of 
the  right  hip.  The  mesentery  of  the  appendix  (Fig.  43), 
which  contains  an  artery  derived  from  the  ileo-colic, 
may  be  so  short  as  to  produce  obstructive  kinks  in  the 
appendix.  The  mucous  lining  is  so  crowded  with  solitary 
Lymphoid  follicles  as  almost  to  occlude  its  lumen.  In 
some  forms  of  appendicitis  these  follicles  are  involved. 
They  are  surrounded  by  lymph  spaces,  from  which 
vessels  pass  to  the  lymph  glands  in  the  mesentery, 
and  others  pass  upwards  behind  the  ascending  colon 
(Lockwood).  It  is  probably  through  these  latter  vessels 
that  infection  passes  from  the  appendix  and  gives  rise 
to  abscesses  in  the  subdiaphragmatic  region.  The 
muscular  coat  of  the  appendix  is  scanty,  and  through 
breaks  in  it  the  submucous  tissue  communicates  with 
the  subserous.  Inflammation  of  the  mucous  membrane 
may  therefore  spread  without  hindrance  to  the 
peritoneum. 

It  is  in  the  ileo-csecal  region  that  intussusception 
most  frequently  occurs.  In  this  condition  one  part  of 
the  intestine  is  prolapsed  or  "  telescoped  "  into  the  lumen 
of  an  immediately  adjoining  part.  In  the  ileo-ca?cal 
variety  (the  commonest  form)  the  narrow  ileum,  and 
subsequently  the  csecum,  are  prolapsed  into  the  colon. 
The  ileo-Ccecal  valve  forms  the  summit  of  the  protrusion 
or  intussusceptum.  By  a  gradual  increase  of  the  con- 
dition the  intussusceptum  bowel  may  at  last  reach 
the  rectum,  and  the  ueo-eaecal  valve  has,  in  fact,  been 
recognised  protruding  from  the  anus.  In  the  ileo-colic 
variety  (the  rarer  form)  the  end  of  the  ileum  is  pro- 
lapsed through  the  valve.  The  valve  and  the  csecum 
remain  in  their  normal  situations,  and  the  summit  of 
the  intussusceptum  is  formed  only  by  the  ileum. 

There  are  three  fairly  constant  peritoneal  fossa?,  which 
are  sometimes  the  seat  of  hernia,  in  the  ileo-ca?cal  region 
(Fig.  43).  They  are  (1)  the  ileo-colic,  situated  between 
the  ascending  colon  and  termination  of  the  ileum  ; 
a  fold  containing  the  anterior  caeca!  artery  bounds  it 


34°  Surgical  Applied  Anatomy.  [Chap.  xvii. 

above ;  (2)  the  ileo-caecal  fossa,  between  the  termination 
of  the  ileum  and  the  caecum  ;  it  is  bounded  in  front  by 
the  bloodless  fold  and  behind  by  the  mesentery  of  the 
appendix  ;  (3)  the  retro-caecal  fossa,  behind  the  caecum  ; 
it  is  bounded  on  the  right  by  the  lower  termination 
of  the  ascending  meso-colon. 

The  large  intestine. — From  the  caecum  to  the 
sigmoid  flexure,  this  portion  of  the  bowel  is  accessible 
to  pressure  except  at  the  hepatic  and  splenic  flexures, 
which  are  deeply  placed.  The  hepatic  flexure  is  under 
the  shadow  of  the  liver,  and  the  splenic  curve,  which 
reaches  a  higher  level,  is  behind  the  stomach.  The 
position  of  the  transverse  colon  can  often  be  well  marked 
out.  It  crosses  the  belly  transversely,  so  that  its  lower 
border  is  on  a  level  with  the  umbilicus  (Fig.  40,  p.  322). 
In  cases  of  faecal  accumulation,  the  outline  of  the  colon, 
with  the  exception  of  the  two  flexures  above  named, 
may  be  distinctly  defined.  In  distensions  of  the  small 
intestine  the  belly  tends  to  present  the  greatest  degree 
of  swelling  in  front,  and  about  and  below  the  navel. 
In  distension  of  the  larger  gut,  the  front  of  the  abdomen 
may  remain  (for  a  while  at  least)  comparatively  flat, 
while  the  distension  will  be  most  obvious  in  the  two 
flanks  and  in  the  region  just  above  the  umbilicus. 
Tumours  of  the  transverse  colon,  and  of  the  lower  two- 
thirds  of  the  ascending  and  descending  colon,  can  be 
well  defined,  even  when  of  moderate  size,  and  in  cases 
of  intussusception  the  progress  of  the  mass  along  the 
colon  can  often  be  traced  with  great  ease,  and  the  effects 
of  enemata  and  other  methods  of  reduction  carefully 
watched.  The  diameter  of  the  large  intestine  (excluding 
the  rectum)  gradually  diminishes  from  the  caecum  to 
the  sigmoid  flexure,  the  diameter  of  the  former  being 
about  2 1-  inches,  of  the  latter  1^  inches.  The  narrowest 
part  of  this  segment  of  the  bowel  is  at  the  point  of 
junction  of  the  sigmoid  flexure  with  the  rectum,  and 
it  is  significant  that  it  is  at  this  point  that  stricture 
is  the  most  common. 

The  tendency  to  stricture  iucreases  as  one  proceeds 
downwards  from  the  caecum  to  the  anus.     A  stricture 


chap,  xvii.]      The  Abdominal    Viscera.  341 

is  frequent  in  the  descending  colon,  less  frequent  in  the 
transverse  colon,  while  in  the  ascending  colon  it  is  com- 
paratively rare.  Strictures  are  not  uncommon  about 
the  flexures  of  the  bowels.* 

When  gradually  distended  the  colon  may  assume 
enormous  dimensions,  and  it  will  be  readily  understood 
that  in  some  cases  of  great  faecal  accumulations  the 
thoracic  organs  may,  with  certain  abdominal  viscera, 
be  displaced.  In  one  case,  for  example,  the  heart  was 
so  displaced  by  the  distended  colon  that  the  apex  beat 
was  found  to  be  \\  inches  above  and  1  inch  to  the  inner 
side  of  the  left  nipple.  Whe n  the  faecal  collection  had  bee n 
removed  it  returned  to  its  normal  position.  Thus  it- 
happens  that  a  distended  colon  is  often  associated  with 
shortness  of  breath,  with  palpitation,  and  other  thoracic 
symptoms. 

The  ascending  and  the  descending  colon  are  placed 
vertically.  The  average  length  of  the  ascending  colon 
in  the  adult  (as  measured  from  the  tip  of  the  caecum 
to  the  hepatic  flexure)  is  8  inches.  The  average  length 
of  the  descending  colon  (from  the  splenic  bend  to  the 
commencement  of  the  sigmoid  flexure)  is  8 \  inches. 
The  descending  colon  is  very  little  liable  to  variation. 
In  cases  of  non-descent  of  the  caecum  the  ascending  colon 
may  be  absent  (page  345).  I  have  pointed  out  that  in 
52  per  cent,  of  adult  bodies  there  is  neither  an  ascending 
nor  a  descending  meso-colon,  and  that  a  meso-colon 
may  be  expected  on  the  left  side  in  36  per  cent,  of  all  cases, 
and  on  the  right  side  in  26  per  cent.  These  points  are 
of  importance  in  connection  with  the  somewhat  uncom- 
mon operation  of  lumbar  colotomy.  The  breadth  of 
the  meso-colon,  when  it  exists,  varies  from  1  to  3  inches. 
The  line  of  attachment  of  the  left  meso-colon  is  usually 
along  the  outer  border  of  the  kidney,  and  is  vertical. 
That  of  the  right  meso-colon  is,  as  a  rule,  less  vertical, 
runs  along  the  inner  border  of  the  kidney,  and  crosses 
its  lower  end  obliquely  from  right  to  left. 

The  transverse  colon  has  an  average  measurement 

*  See  "  Intestinal  Obstruction."      By  the  Author.     London. 

IS'.!'.  I. 


342  Surgical  Applied  Anatomy.  [Chap.  xvii. 

of  20  inches.  It  is  not  quite  horizontal,  since  the  splenic 
flexure  is  on  a  higher  level  than  the  hepatic  flexure, 
as  well  as  posterior  to  it.  Faecal  masses  lodged  in  the 
transverse  colon  have  given  rise  to  many  errors  in  dia- 
gnosis. In  some  instances  this  part  of  the  colon  is  dis- 
placed towards  the  pelvis,  so  that  V-  or  U-shaped  bends 
are  produced.  In  such  cases  the  point  of  the  V  or  U 
may  reach  the  symphysis  pubis,  while  the  two  colic 
flexures  occupy  their  proper  situations.  These  devia- 
tions are  described  in  detail  in  my  work  on  Intestinal 
Obstruction. 

The  right-hand  part  of  the  transverse  colon  is  in 
intimate  relation  with  the  gall  bladder,  and  is  commonly 
found  to  be  bile-stained  after  death.  In  some  cases 
where  gall  stones  have  been  lodged  within  the  gall 
bladder,  the  walls  of  that  structure  have  ulcerated 
from  pressure,  the  ulceration  has  involved  the  sub- 
jacent transverse  colon,  and  thus  a  fistula  has  been 
established  between  the  gall  bladder  and  the  gut,  through 
which  large  stones  have  been  passed.  Hepatic  abscesses 
also  have  discharged  themselves  through  the  transverse 
colon.  The  transverse  colon  often  finds  its  way  into 
an  umbilical  hernia,  and  has  been  found  to  be  concerned 
in  many  of  the  cases  of  hernia  into  the  foramen  of 
Winslow. 

The  sigmoid  flexure. — The  segments  of  gut  termed 
the  sigmoid  flexure  and  "  the  first  part  of  the  rectum  " 
form  together  a  single  simple  loop  that  cannot  be  divided 
into  parts.  This  loop  begins  where  the  descending  colon 
ends,  and  ends  at  the  commencement  of  the  so- 
called  "  second  part  of  the  rectum ;  "  at  a  spot,  in  fact, 
where  the  meso-rectum  ceases,  opposite  about  the  third 
piece  of  the  sacrum.  This  loop,  when  unfolded,  describes 
a  figure  that,  if  it  must  be  compared  to  a  letter,  resembles 
the  capital  Omega.  It  may  well  be  termed  the  Omega 
loop,  and  the  term  rectum  be  limited  to  the  short  piece 
of  practically  straight  gut,  that  is  now  described  as  the 
second  and  third  parts  of  the  rectum.  The  average 
length  of  the  loop  in  the  adult  is  Yl\  inches.  The  two 
extremities  of  the  loop  are  about  3  or  4  inches  apart. 


Chap,  xvii.]      The  Abdominal   Viscera.  343 

If  tliey  are  approximated  to  one  another,  as  by  contract- 
ing peritonitis  at  the  root  of  the  sigmoid  meso-colon, 
a  kind  of  pedicle  is  established,  about  which  the  loop 
may  readily  become  twisted.  Such  a  twist  of  the  bowel 
constitutes  a  volvulus  of  the  sigmoid  flexure  ;  and  it 
may  be  here  said  that  volvulus  of  the  intestine  is  more 
commonly  met  with  in  this  loop  than  in  any  other  part 
of  the  canal. 

The  line  of  attachment  of  the  meso-colon  of  the 
Omega  loop  (the  sigmoid  meso-colon)  crosses  the  psoas 
muscle  and  the  iliac  vessels  near  their  bifurcation  ;  it 
then  turns  abruptly  down,  and  running  nearly  vertically, 
terminates  at  the  middle  line. 

In  the  left  wall  of  this  meso-colon,  close  to  the  point 
where  it  lies  over  the  iliac  vessels,  a  fossa  is  sometimes 
to  be  found.  It  is  produced  by  the  sigmoid  artery, 
and  is  about  1^  inches  in  depth.  It  is  called  the  inter- 
sigmoid  fossa,  and  is  the  seat  of  sigmoid  hernia 
(Fig.  44,  m.c).  Two  cases  of  strangulated  hernia  in 
this  fossa  have  been  recorded. 

The  sigmoid  flexure,  or  Omega  loop,  when  empty, 
normally  occupies  the  pelvis.  When  distended  this 
piece  of  bowel  may  become  so  enormously  dilated  as 
to  reach  the  liver.  The  chief  examples  of  extraordinary 
dilatation  of  the  colon  concern  this  loop.  Faecal  masses 
are  very  frequently  lodged  in  the  free  end  of  the  loop 
and  certain  intestinal  concretions  have  been  met  with 
in  the  same  situation. 

I  have  shown  by  experiment  that  the  "long  tube." 
when  introduced  through  the  anus,  cannot  be  passed 
beyond  the  sigmoid  flexure  in  ordinary  cases,  and  with 
a  normal  disposition  of  the  bowel. 

In  cases  of  congenital  absence,  or  deficiency  of  the 
rectum,  the  sigmoid  flexure  is  often  opened  in  the 
groin  and  an  artificial  anus  established  there.  This 
operation,  known  as  Littre's  operation,  is,  it  must  be 
confessed,  not  very  successful.  One  difficulty  has  been 
said  to  depend  upon  the  uncertain  position  of  the  sig- 
moid flexure  in  cases  of  congenital  deformity,  it  being 
sometimes  on  the  right  side  and  sometimes  in  the  pelvis 


344 


Surgical  Applied  Anatomy.  [Chap.  xvii. 


at  the  middle  line.  It  is  rarely,  however,  found  in  these 
positions.  Out  of  100  post-mortem  examinations  on 
young  infants,  Curling  found  the  loop  on  the  left  side 
in  eighty-five  cases.  Out  of  ten  children  who  were 
operated  on  for  imperforate  anus,  the  loop  was  found  in 
the  left  fossa  in  only  one  case  (Montgomery). 


Fig.    44.— Sigmoid  Flexure  turned  upwards  to  show  the  Inter-signioid 
fossa  (Jonnesco). 

s  v,  Sigmoid  flexure  ;  a  s,  Sigmoid  artery  :  w  c,  Meso-sigmoid  fossa ;  a  e,  external 
il:ac  artery ;  u,  Ureter  in  front  of  internal  iliac  vessels. 

The  sigmoid  flexure  is  the  part  of  the  colon  opened 
in  the  operation  of  left  iliac  or  inguinal  colotomy.  In 
performing  this  operation  the  length  of  the  sigmoid 
meso-colon  and  the  consequent  mobility  of  the  coil  are  of 
much  importance. 

The  sigmoid  flexure,  when  empty  and  contracted,  can 
be  felt  through  the  parietes  in  moderately  thin  subjects. 


chap,  xvii.]      The  Abdominal   Viscera.  345 

Congenital  malformations  of  the  colon.— 

These  are  of  moment  with  regard  to  operative  pro- 
cedures. It  may  be  very  briefly  said  that  in  the  foetus 
the  small  bowel  occupies  at  one  time  the  right  side  of 
the  abdomen,  while  the  large  gut  is  represented  by  a 
straight  tube  that  passes  on  the  left  side  vertically 
from  the  region  of  the  umbilicus  to  the  pelvis.  The 
caecum  is  at  first  situated  within  the  umbilicus,  and  then 
ascends  in  the  abdomen  towards  the  left  hypochon- 
driuni.  It  next  passes  transversely  to  the  right  hypo- 
chondrium,  and  then  descends  into  the  corresponding 
iliac  fossa.  It  may  be  permanently  arrested  at  any  part 
of  its  course.  Thus  the  caecum  may  be  found  about  the 
umbilicus,  or  in  a  congenital  umbilical  hernia,  or  in  the 
left  hypochondriac  region  (the  ascending  and  trans- 
verse parts  of  the  colon  being  absent),  or  it  may  be  found 
in  the  right  hypochondrium,  the  ascending  colon  only 
being  unrepresented. 

The  whole  of  the  large  intestine  has  at  one  time 
an  extensive  mesentery,  and  in  some  rare  cases  this 
condition  may  persist  throughout  life.  When  it  does 
persist,  it  may  lead  to  one  form  of  volvulus  of  the  bowel. 

Lumbar  colotomy. — The  operation  so  named 
consists  in  opening  the  colon  in  the  loin  behind  the 
peritoneum,  for  the  purpose  of  establishing  an  artificial 
anus.  The  operation  is  performed,  when  possible, 
upon  the  left  side,  in  preference  to  the  right,  inasmuch 
as  the  descending  colon  is  nearer  to  the  anus.  The 
operation  has,  however,  been  almost  entirely  superseded 
by  iliac  colotomy  except  in  a  few  uncommon  conditions. 
The  position  of  the  descending  colon  in  the  loin  may  be 
represented  by  a  line  drawn  vertically  upwards  from 
a  point  \  an  inch  behind  the  centre  of  the  iliac 
crest  (Fig.  50,  p.  365).  In  performing  left  lumbar 
colotomy  an  ink  line  may  be  drawn  vertically 
upwards  from  the  centre  of  the  crest  of  the 
ilium.  It  will  hit  the  outer  end  of  the  last  rib.  An 
incision  is  made  across  the  centre  of  this  line  parallel 
to  the  last  rib,  and  so  planned  that  the  centre  of  the 
incision  corresponds   to   the   centre   of   the   line.     The 


346 


Surgical  Applied  Anatomy.  [Chap. xvii. 


superficial  tissues  having  been  incised,  the  following 
structures  are  then  divided  in  layers  in  the  following- 
order  :  (1)  The  latissimus  dorsi  and  external  oblique 
muscles  to  an  equal  extent.     (2)    The  internal  oblique 


Fig.   45.—-  Horizontal  Section  through  the  Body  at  the  Level  of  the 
Umbilicus.     (After  Braune.) 

a,  Spine  of  the  fourth  lumbar  vertebra  ;  6,  disc  between  third  and  fourth  verte- 
brae ;  c,  umbilicus  ;  d,  quadratus  lumborum ;  e,  psoas  ;  /,  external  oblique, 
with  internal  oblique  and  transversalis  muscles  beyond ;  y,  rectus ;  h,  de- 
scending colon ;  i,  transverse  colon ;  j,  aorta ;  ft,  inferior  vena  cava ;  I, 
ureter. 

in  the  entire  length  of  the  incision.  (3)  The  fascia 
lumborum,  with  a  few  of  the  most  posterior  fibres  of  the 
transversalis  muscle.  (4)  The  transversalis  fascia. 
The  quadratus  lumborum  will  be  exposed  in  the  posterior 
inch  or  so  of  the  incision,  and  usually  does  not  need  to 


Chap,  xvn  ]      The  Abdominal   Viscera.  347 

be  cut.  At  the  seat  of  the  operation  the  descending 
colon  occupies  the  angle  between  the  psoas  and  quad- 
ratus  lumborum  muscles,  and  the  non-peritoneal  surface 
is  exactly  represented  by  that  part  of  the  bowel  that 
faces  this  angle  (Fig.  45).  Thus,  if  during  the  operation 
the  curved  finger  be  placed  in  this  angle,  and  the  patient 
be  rolled  over  to  the  left  side,  the  bowel  that  falls  into 
the  finger  cannot  well  be  other  than  the  descending 
colon.  The  gut  is  drawn  forwards,  stitched  to  the 
wound,  and  opened  by  a  transverse  cut.  The  width 
of  the  non-peritoneal  surface  varies  from  £ths  of  an  inch 
to  1  inch  in  the  empty  state,  and  may  attain  to  2  inches 
or  more  in  the  distended  condition  (Braune).  The 
part  of  the  descending  colon  usually  opened  is  the  highest 
portion  of  that  bowel,  so  that  the  finger  can  often  be 
thrust  into  the  transverse  colon,  or  the  opening  of  the 
intestine  can  be  seen.  In  this,  as  in  other  circumstances, 
the  large  bowel  may  be  distinguished  from  the  small 
by  its  sacculi,  its  three  longitudinal  muscular  bands, 
and  its  appendices  epiploicse.  As  regards  dimensions, 
the  small  intestine  may,  especially  in  cases  of  obstruction, 
be  much  larger  than  the  so-called  large  intestine.  When 
empty,  the  diameter  of  the  descending  colon  is  about 
equal  to  that  of  the  jejunum,  the  measurement  in  the 
two  cases  being  about  H-  inches.  The  average  dia- 
meter of  the  ileum  is  1 }  inches,  and  of  the  csecum  and 
commencing  colon  2.1  inches. 

Lumbar  colotomy  is  often  performed  through  a 
vertical  or  oblique  incision  in  the  place  of  the  one  just 
given. 

The  operation  does  not  materially  differ  from  that 
described,  when  it  is  performed  on  the  right  side. 

Iliac  or  inguinal  colotomy. — In  this  very 
common,  excellent,  and  simple  operation  the  sigmoid 
flexure  is  exposed  and  opened  in  the  left  iliac  region. 
A  line  is  drawn  from  the  anterior  superior  iliac  spine  to 
the  umbilicus,  and  an  incision  some  2  inches  in  length 
is  made  at  right  angles  to  this  line  and  at  a  distance  of 
about  \\  inches  from  the  point  of  the  bone.  The  three 
muscles  of  the  abdomen  and  the  peritoneum   having 


348  Surgical  Applied  Anatomy.  [Chap.  xvn. 

been  divided,  the  loop  of  the  sigmoid  flexure  is  brought 
into  the  wound,  is  secured,  and  is  (at  once  or  at  a  later 
period)  opened. 

The  caecum  may  be  opened  on  the  right  side,  and 
as  a  rule  the  most  convenient  incision  is  an  oblique  one 
placed  external  to  the  deep  epigastric  artery. 

Colectomy  consists  in  excising  a  portion  of  the  colon. 
The  caecum  has  been  removed,  and  considerable  segments 
of  the  rest  of  the  large  intestine.  The  treatment  of 
cancer  of  the  colon  by  excision  is  attended  with  very 
considerable  success.  Portions  of  the  ascending  and 
descending  parts  of  the  colon  have  been  excised  through 
an  incision  in  the  loin,  but  colectomy  is  much  more 
readily  carried  out  through  an  anterior  wound.  I 
have  reported  a  case  in  a  young  girl,  in  which  I  excised 
the  whole  rectum  and  anus,  the  sigmoid  flexure,  and 
the  whole  of  the  descending  colon.  The  divided  trans- 
verse colon  was  brought  out  at  the  anus.  The  child 
made  a  perfect  recovery.  The  parts  removed  are  in 
the  Museum  of  the  Royal  College  of  Surgeons.  The 
operation  of  intestinal  anastomoses  or  short  circuiting 
is  very  frequently  practised  on  the  colon.  Thus,  in  an 
obstruction  on  the  descending  colon  incapable  of  removal, 
the  transverse  colon  may  be  united  to  the  sigmoid 
flexure. 

The  liver — The  liver  is  moulded  to  the  arch  of 
the  diaphragm,  and  lies  over  a  part  of  the  stomach 
(Fig.  48).  The  convex  surface  is  protected  on  the  right 
side  by  the  ribs,  from  the  seventh  to  the  eleventh  in- 
clusive, and  in  front  by  the  xiphoid  cartilage  and  the 
costse  from  the  sixth  to  the  ninth  inclusive,  the  dia- 
phragm being  interposed.  The  diaphragm  separates 
the  liver  from  the  thin  margin  of  the  base  of  the  right 
lung,  which  descends  in  front  of  it.  Its  pointed  left 
extremity  reaches  the  position  of  the  apex  beat,  and  in 
the  early  years  of  life,  when  the  left  lobe  is  relatively 
large,  it  may  touch  the  spleen,  a  relationship  sometimes 
met  with  in  the  adult.  In  the  subcostal  or  infrasternal 
triangle,  the  liver  lies  in  front  of  the  stomach  and 
beneath  the  anterior  abdominal  wall.     The  lower  edge, 


Chap,  xvii.]      The  Abdominal    Viscera. 


349 


as  it  crosses  the  subcostal  angle,  is  represented  by 
a  line  drawn  from  the  ninth  right  to  the  eighth 
left  costal  cartilage  (Fig.  40,  p.  322).  In  the  erect  posture 
the  lower  edge  on  the  right  side  is  about  \  or  \ 
of  an  inch  below  the  margins  of  the  costal  cartilages. 


LIVER 


CYSTIC  DUCT. 


FOR.  WIN.- I 

COM.  BILE  D 

IV  ST 

LY.  GL._ 

VENA  CAVA  . 


COM.  BILE  P.  i 
2V     S' 


HEAD    OF    PAN 


Fig.  46. — Diagrammatic  Representation  of  the  Gall  Bladder  and  Bile  Ducts 
from  the  right  side. 

The  position  of  the  portal  vein  is  indicated  by  x  ;  or-.  BL.,  gall  bladder;  coir. 
bile  d.  1st  ST.,  omental  stage  of  common  bile  duct:  com.  bile  d.  2nd  ST., 
retro-duodenal  stage  of  common  bile  duct ;  hep.  art,,  bepatic  artery  giving 
off  the  gastro-duodenal  and  superior  pancreatico-duodenal  artery;  for.  WIN., 
foramen  of  Winslow;  ix.  c.c,  tip  of  ninth  costal  cartilage;  1st  ST.  d.,  first 
stage  of  duodenum;  2nd  ST.  n..  second  stage  of  duodenum;  trass,  col. , 
section  of  transverse  colon;  LY.  gl.,  lymph  glands  in  the  gastro-hepatic 
omentum. 


In  the  recumbent  position  the  liver  ascends  about 
an  inch,  and  is  entirely  covered  by  the  costse, 
except  at  the  subcostal  angle.  It  descends  also  in 
inspiration  and  rises  in  expiration.  The  liver  reaches 
its  highest  level  in  the  nipple  line  at  a  point  marked  by 
the  fifth  rib.  To  the  left  it  slopes  downwards  to  the  apex 


356  Surgical  Applied  Anatomy,  tChap.  xvii. 

beat,  the  line  crossing  the  sternum  at  the  insertion  of 
the  sixth  pair  of  ribs.  To  the  right  of  the  nipple  line,  it 
rapidly  descends,  passing  the  seventh  rib  in  the  axillary 
line  and  the  ninth  below  the  angle  of  the  scapula. 
Behind,  the  liver  comes  to  the  surface  below  the  right 
lung,  at  a  part  corresponding,  both  in  position  and 
width,  to  the  tenth  and  eleventh  dorsal  vertebrse.  On 
the  extreme  right  the  liver  descends  to  the  level  of  the 
second  lumbar  spine  (Figs.  41  and  48).  The  under 
surface  of  the  liver  is  in  contact  with  the  stomach,  the 
first  and  second  parts  of  the  duodenum,  the  small 
omentum,  the  right  kidney,  and  the  beginning  of  the 
transverse  colon. 

The  fundus  of  the  gall-bladder  approaches  the  surface 
behind  the  ninth  costal  cartilage,  close  to  the  outer 
border  of  the  right  rectus  muscle. 

The  liver  is  retained  in  shape  by,  and  moulded  upon, 
the  diaphragm  above  and  the  abdominal  organs  below. 
When  removed  from  the  body  the  shape  is  lost  which 
it  possesses  clinically.  It  presents  many  variations  in 
form.  One  of  the  commonest  is  a  linguiform  process, 
usually  known  as  RiedeVs  lobe,  which  projects  from 
the  margin  of  the  right  lobe  under  the  tenth  costal 
cartilage.  It  is  found  more  frequently  in  women  than 
in  men,  and  may  be  mistaken  for  a  floating  kidney  or 
an  abdominal  tumour. 

In  the  condition  known  as  ptosis  of  the  liver  the 
organ  slides  from  the  dome  of  the  diaphragm,  and  may 
descend  to  the  level  of  the  umbilicus  or  reach  the  iliac 
fossa.  With  the  descent  there  is  also  a  rotation  on  its 
transverse  axis,  so  that  its  diaphragmatic  surface  comes 
almost  completely  to  the  front.  In  such  a  case  the 
factors  which  maintain  the  liver  in  position  have  to  be 
considered.  They  are  :  (1)  its  fixation  to  the  diaphragm 
by  the  inferior  vena  cava  and  the  fibrous  tissue  on  the 
non-peritoneal  posterior  surface  of  the  right  lobe  in  the 
neighbourhood  of  the  inferior  vena  cava.  This  is  its 
chief  support.  (2)  The  peritoneal  folds,  which  include  the 
right  and  left  lateral,  coronary,  and  falciform  ligament, 
also   attach    it   to  the  diaphragm.     (3)  The   muscular 


Chap,  xvii.]      The  Abdominal   Viscera.  351 

abdominal  walls.  These  keep  the  other  abdominal 
viscera  constant])-  pressed  against  the  lower  surface  of 
the  liver.  It  must  be  remembered  that  in  respiration 
the  liver  plays  the  part  of  shuttlecock  to  the  battledore 
of  the  diaphragm  and  abdominal  parietes.  In  many 
women  over  forty  the  right  lobe  of  the  liver  projects 
quite  2  inches  below  the  eleventh  rib. 

The    liver  is  more  often   ruptured  from  contusion 
than  is  any  other  abdominal  viscus.     This  is  explained 
by  its  large  size,  its  comparatively  fixed  position,  and 
its    great  friability  of  structure.       Death  in  such  in- 
juries usually  ensues  from  hseniorrhage,  since  the  walls 
of   the   portal   and  hepatic   veins,    being   incorporated 
with  the  liver  substance,  are  unable  to  retract  or  to 
collapse.     The  hepatic  veins  also  open  direct  into  the 
vena  cava,  and,  being  unprovided  with  valves,  could 
allow  of  the  escape  of  an  immense  quantity  of  blood, 
if    any    retrograde     current    were    established.       The 
hepatic  vessels  are  thin-walled,  and  it  is  almost  impos 
sible  to  ligature  them,  except  by  buried  sutures.     It  is 
possible  for  the  liver  to  be  ruptured  without  the  peritoneal 
coat   being   damaged.     Such   injuries   may   be    readily 
recovered  from.     The  liver  presents,   behind,   a  fairly 
extensive  non-peritoneal  surface,  at  which  rupture  or 
wound    may    occur    without    extravasation    into    the 
abdominal  cavity.     From  the  relation  of  the  liver  to 
the  right  lower  ribs,  it  follows  that  this  viscus  may  be 
damaged  when  the  ribs  are  fractured,   and  in  some 
cases  the  broken  ends  of  the  bones  have  been  driven 
through  the  diaphragm  into  the  liver  substance.     Stabs 
through  the  sixth  or  seventh  right  intercostal  space, 
over  the  liver  region,  would  wound  both  the  lung  and 
the  liver,  would  involve  the  diaphragm,  and  open  up 
both  the  pleural  and  peritoneal  cavities.     The  intimate 
relation  of  the  liver  to  the  transverse  colon  is  illus- 
trated by  a  case  where  a  toothpick,  4  inches  in  length, 
was  found  in  the  substance  of  the  liver.     It  had  worked 
its  way  there,  from  the  colon,  along  an  abscess  cavity 
that  connected  the   two  viscera.     The  relation   of  the 
iiver  to  the  heart  may  be  illustrated  by  a  case  still  more 


352  Surgical  Applied  Anatomy.  [Chap. xvii. 

remarkable.  In  this  instance  a  loose  piece  of  liver, 
weighing  1  drachm,  was  found  in  the  pulmonary  artery. 
The  patient  had  been  crushed  between  two  waggons, 
the  liver  was  ruptured,  and  the  diaphragm  torn.  A 
piece  of  the  liver  had  been  squeezed  along  the  vena  cava 
into  the  right  auricle,  whence  it  had  passed  into  the 
right  ventricle,  and  so  into  the  pulmonary  artery.  The 
heart  itself  was  quite  uninjured.  Portions  of  the  liver 
may  protrude  through  abdominal  wounds,  and  are 
usually  easy  to  reduce.  In  one  instance  of  such  pro- 
trusion the  surgeon  did  not  find  the  reduction  easy, 
so  he  placed  a  ligature  round  the  projecting  part  of  the 
viscus,  and  then  cut  this  obstinate  portion  of  the  liver 
off.  The  patient  recovered.  Considerable  portions  of 
the  liver  have  been  removed  with  success.  It  is  remark- 
able from  what  grave  injuries  of  the  liver  recovery  is 
possible.  Thus,  Dr.  Gann  {Lancet,  June,  1894)  reports 
the  case  of  a  man  of  28,  who  had  a  harpoon  driven 
through  the  whole  thickness  of  the  right  lobe  of  the 
liver,  so  that  it  projected  at  the  posterior  border.  The 
blade  was  7  inches  long,  and  had  two  barbs.  It  was 
removed  by  operation  twenty-eight  hours  after  the 
accident,  and  the  patient  made  a  good  recovery. 

From  a  reference  to  the  relations  of  the  liver,  it 
will  be  readily  understood  that  an  hepatic  abscess  may 
open  into  the  pleura,  and  in  some  cases,  indeed,  the 
pus  from  the  liver  has  been  discharged  from  the  bronchi. 
Thus,  it  has  been  possible  for  a  patient  to  cough  up 
some  portion  of  his  liver,  although,  of  course,  in  a  very 
disintegrated  and  minute  form.  Hepatic  abscess  may 
burst  in  one  or  other  of  the  following  directions,  placed 
in  order  of  their  frequency  :  (1)  Into  the  right  lung ;' 
(2)  into  the  bowel ;  (3)  upon  the  surface  of  the  body. 
Such  abscesses  have,  in  rare  cases,  opened  into  the 
stomach.  The  liver  is  very  frequently  the  seat  of  the 
secondary  abscess  of  pyaemia,  and,  according  to  Mr. 
Bryant's  statistics,  abscesses  in  this  viscus  are  more 
common  after  injuries  to  the  head  than  after  injuries 
elsewhere.  They  are  rare  in  pyaemia  following  affections 
of  the  urinary  organs,  and  are  equally  rare  in  the  pyaemia 


353 


a— 


mm    I , 


Fig.  17— View 


>f  some  of  the  Abdominal  Viscera  from  behind 
(Rildinger). 


a,  Tboracic  aorta ;  b,  oesophagus;  c,  common  carotid  artery  and  internal  jugular 
vein  ;  d,  root  of  right  lung ;  a, inferior  vena  cava  j  f,  spleen  ;  g,  stomach,  and 
to  its  right  the  liver  ;  h,  pancreas ;  i,  descending  part  of  duodenuinf  opened  ; 
j.  sni'eri  >r  mesanterie  vein  joined  by  splenic  above  ;  k,  ascending  colon  ;(.  do- 
sccu'ling'olo  i  ;  m  superior  hemorrhoidal  vein  joining  inferior  mesenteric. 


354  Surgical  Applied  Anatomy.  [Chap.  xvii. 

after  burns.  The  liver  is  more  often  the  seat  of  hydatid 
cyst  than  are  all  the  viscera  taken  together.  The  cyst  may 
discharge  itself  externally,  or  into  the  pleural  or  perito- 
neal cavities,  or  into  any  adjacent  part  of  the  intestine. 

The  gall  bladder  may  be  absent,  as  is  the  case 
with  some  animals,  or  reduced  to  a  cicatrix  from  disease. 
Its  mucous  membrane  has  a  peculiar  reticulated,  honey- 
comb appearance.  It  is  often  occupied  by  gall  stones. 
These  concretions  are  composed  mostly  of  cholesterin, 
a  normal  constituent  of  bile,  and  vary  in  size  from  a 
hemp  seed  to  a  hen's  egg.  The  escape  of  gall  stones  is 
rendered  more  difficult  by  the  presence  of  a  spiral  fold 
of  mucous  membrane  in  the  neck  and  duct  of  the  gall 
bladder.  The  gall  bladder,  at  its  neck,  forms  an  acute 
angle  with  the  cystic  duct,  the  spiral  fold  being  necessary 
to  keep  the  passage  open.  In  the  erect .  position  the 
long  axis  of  the  gall  bladder  is  directed  upwards  and 
backwards,  and  the  cystic  duct  downwards  and  for- 
wards (Fig.  46).  The  cystic  duct  lies  in  the  gastro-hepatic 
omentum,  where  it  joins  the  hepatic  to  form  the  common 
bile  duct.     It  is  accompanied  by  the  cystic  artery. 

A  gall  stone  may  be  arrested,  and  require  removal, 
from  any  part  of  the  cystic  or  common  bile  ducts.  The 
common  bile  duct  is  3  inches  long,  and  its  lumen  Ath  of  an 
inch  wide,  but  by  the  passage  of  the  gall  stones  it  may 
become  three  times  its  normal  diameter.  The  upper 
half  of  the  common  bile  duct  lies  in  the  gastro-hepatic 
omentum,  in  front  of  the  foramen  of  Winsiow,  with  the 
portal  vein  behind  it  and  to  the  right  (Fig.  46).  The 
hepatic  artery  lies  close  to  it  on  the  left,  and  its  branch, 
the  superior  pancreatico-duodenal,  crosses  the  common 
bile  duct  as  it  passes  to  its  second  or  deeper  stage.  A  stone 
arrested  in  the  lower  half  of  the  duct  is  difficult  of  access. 
The  duct  lies  buried  between  the  head  of  the  pancreas 
behind  and  the  duodenum  in  front  and  to  the  outer 
side.  It  may  be  necessary  in  such  a  case  to  open  the 
duodenum  and  extract  the  stone  through  its  posterior 
and  inner  wall.  Two  lymphatic  glands  lie  in  the  gastro- 
hepatic  omentum  by  the  side  of  the  bile  duct,  and  have 
been  mistaken  for  gall  stones  when  calcified. 


Chap,  xvii.]      The  Abdominal    Viscera.  355 

The  gall  bladder  receives  its  nerve  supply  from  the 
eighth  and  ninth  segments  of  the  cord  (Head)  through 
the  great  splanchnic  and  cceliac  plexus. 

The  gall  bladder  and  the  bile  duct  have  been  rup- 
tured alone  without  rupture  of  the  liver.  The  injury 
is  rapidly  fatal,  owing  to  the  escape  of  bile  into  the 
peritoneal  cavity.  Large  gall  stones  are  passed  direct 
into  the  bowel  through  a  fistulous  tract  that  has  been 
established  between  the  gall  bladder  and  the  intestine. 
Gall  stones  have  suppurated  out  through  the  anterior 
belly  wall,  and  have  been  removed  from  abscesses  in 
the  parietes.  Thus  Dr.  Burney  Yeo  reports  a  case 
where  more  than  one  hundred  gall  stones  were  dis- 
charged through  a  spontaneous  fistula  in  the  hypo- 
gastric region,  5  inches  below  the  umbilicus.  In  cases 
where  the  bile  duct  is  occluded  by  gall  stones,  or  by 
other  causes,  the  gall  bladder  may  become  enormously 
distended,  and  may  form  a  tumour  extending  some  way 
beyond  the  umbilicus.  So  large  a  tumour  has  been 
formed  that  the  mass  has  been  mistaken  for  an  ovarian 
cyst.  The  gall  bladder  as  it  enlarges  tends  to  follow 
a  line  extending  from  the  tip  of  the  right  tenth  cartilage 
across  the  median  line  of  the  abdomen  below  the  umbili- 
cus. For  the  relief  of  this  condition,  cholecystotomy,  or 
incision  into  the  gall  bladder,  has  been  performed.  In 
this  operation  the  incision  or  puncture  is  made  over  the 
most  prominent  part  of  the  tumour.  Impacted  gall 
stones  have  teen  removed  entire  from  the  bile  duct 
through  an  incision  so  made,  or  the  stone  has  been 
crushed  in  situ  and  extracted  in  fragments. 

In  cholecystectomy  the  whole  of  the  gall  bladder  is 
excised  and  the  cystic  duct  closed.  The  bile  finds  its  way 
into  the  intestine  direct  through  the  common  duct. 

In  cholecystenterostomy  a  fistula  is  established  be- 
tween the  gall  bladder  and  the  intestine.  The  operation 
is  carried  out  in  cases  in  which  there  is  an  insuperable 
obstruction  in  the  common  duct.  The  gall  bladder  thus 
takes  the  place  of  the  common  duct. 

The  spleen. — The  spleen  is  deeply  situated  in  the 
left  hypochondriac  region,  and  in  the  normal  condition 


356 


Surgical  Applied  Anatomy.  [Chap.  xvn. 


cannot  be  palpated,  being  quite  covered  in  front  by  the 
cardiac  end  of  the  stomach.  It  most  closely  approaches 
the  surface  in  the  parts  covered  by  the  tenth  and 
eleventh  ribs.  Above  this  it  is  entirely  overlapped  by  the 
edge  of  the  lung.  It  is  in  all  parts  separated  from  the 
parietes  by  the  diaphragm.  "  It  lies  very  obliquely,  its 
long  axis  coinciding  almost  exactly  with  the  line  of  the 
tenth  rib.     Its  highest  and  lowest  points  are  on  a  level, 


Y\g.  is.— Horizontal  Section  through  Upp^r  part  of  Abdomen. 
(Riidinger.) 

a,  Livsr ;  b,  stomach  ;  c,  transverse  colon  ;  d,  spleen  :  e,  kidney*  ;  /,  pancreas  ; 
g,  inferior  vena  cava  ;  h,  aorta  with  thoracic  duct  behind  it. 

respectively,  with  the  ninth  dorsal  and  first  lumbar 
spines  ;  its  inner  end  is  distant  about  l|-  inches  from 
the  median  plane  of  the  body,  and  its  outer  end  about 
reaches  the  mid-axillary  line "  (Quain)  (Figs.  41  and 
47).  It  possesses  three  surfaces,  gastric,  renal,  and 
phrenic,  well  shown  in  Fig.  48. 

A  dislocated  or  floating  condition  of  the  spleen  is 
rare.  Its  renal  surface  is  fixed  firmly  to  the  upper 
half  of  the  left  kidney ;  its  gastric  surface  is  kept  in 
apposition  to  the  stomach  by  the  gastro-splenic  omentum  ; 


chap,  xvii.]      The  Abdominal    Viscera.  357 

its  upper  pole  is  attached  near  the  cardiac  orifice  of  the 
diaphragm  by  a  suspensory  fold  of  peritoneum,  while 
its  lower  rests  on  the  costo-colic  peritoneal  fold,  and  has 
the  tail  of  the  pancreas  and  colon  in  contact  with  it. 
The  tension  of  the  abdominal  walls  exerts  a  general 
pressure  on  it  through  the  other  abdominal  organs. 
When  the  spleen  enlarges,  as  in  ague,  its  crenated 
anterior  border  may  be  felt  beneath  the  tenth  costal 
cartilage.  The  movable  or  floating  spleen  is  met  with 
only  in  adults.  The  organ  may  be  so  displaced  as  to 
reach  the  iliac  fossa. 

Injuries. — Although  extremely  friable  in  structure, 
the  normal  spleen  is  not  very  frequently  ruptured. 
Its  connections,  indeed,  tend  to  minimise  the  effects 
of  concussions  and  contusions.  It  is  swung  up  by  the 
peritoneum,  rests  upon  the  elastic  costo-colic  fold,  and 
is  protected  by  the  stomach  and  lungs  to  a  considerable 
extent.  When  the  spleen,  however,  is  enlarged,  it  is 
very  readily  ruptured,  and  often  by  quite  insignificant 
violence.  Thus,  several  cases  have  been  recorded  of 
rupture  of  an  enlarged  spleen  by  muscular  violence. 
For  instance,  a  woman  ruptured  her  spleen  in  an 
attempt  to  save  herself  from  falling,  and  another  in 
springing  aside  to  avoid  a  blow.  The  patients  in  each 
instance  were  natives  of  India,  and  the  latter  case 
gave  rise  to  a  charge  of  homicide.  The  spleen  being 
extremely  vascular,  it  follows  that  ruptures  of  the  viscus 
are  usually,  but  not  necessarily,  fatal  from  ha?morrhage. 
It  is  well  to  note,  in  connection  with  this  matter,  that 
the  spleen  contains  most  blood  during  digestion.  A 
case  is  reported,  however,  of  a  boy  who  met  with  an 
accident  just  after  dinner,  and  who  managed  to  walk 
some  distance,  although  his  spleen,  as  the  autopsy  re- 
vealed, was  separated  into  three  portions.  He  lived 
some  days.  In  severe  fractures  of  the  ninth,  tenth, 
and  eleventh  ribs  the  spleen  may  be  damaged  and 
lacerated. 

The  capsule  of  the  spleen  contains  muscular  tissue, 
and  must  possess  some  contractile  power.  This  fart 
may  serve  to  explain  cases  of  recovery  from  limited 


358  Surgical  Applied  Anatomy.  [Chap.  xvn. 

wounds  of  the  organ,  such  as  small  gunshot  wounds. 
In  such  lesions  the  capsule  may  contract  and  greatly 
narrow  the  hole  in  the  viscus,  while  the  track  of  the 
bullet  or  knife  may  become  filled  with  blood-clot,  and 
the  bleeding  thus  be  stayed. 

The  spleen  may  be  greatly  enlarged  in  certain 
diseased  conditions.  The  hypertrophied  spleen  may 
attain  such  dimensions  as  to  fill  nearly  the  whole  abdo- 
men, and  in  one  case  a  cystic  tumour  so  completely 
occupied  both  iliac  fossae  that  it  was  mistaken  for  an 
ovarian  cyst,  and  the  operation  for  ovariotomy  was 
commenced.  It  is  said  that  the  enlarged  spleen,  in 
its  earlier  stages,  encroaches  upon  the  thoracic  cavity 
relatively  more  in  the  child  than  in  the  adult.  This 
is  explained  by  the  statement  that  the  costo-colic  fold, 
upon  which  the  spleen  rests,  is  much  more  resisting 
in  the  young  than  it  is  in  those  of  more  mature  age. 

Extirpation  of  the  spleen  has  been  suc- 
cessful in  cases  of  abdominal  wounds  with  protrusion 
of  the  viscus.  It  has  also  been  performed  with  fair 
results  in  many  cases  of  hypertrophied  spleen,  and  of 
wandering  spleen.  The  operation  is  not  justifiable  in 
cases  of  leuksemic  enlargement  of  the  organ,  it  having 
proved  invariably  fatal  in  such  instances.  In  cases  of 
wounds  with  protrusion,  the  spleen  is,  of  course,  removed 
through  the  wound.  In  other  instances  the  incision 
is  usually  made  in  the  middle  line,  the  most  convenient 
being  one  so  arranged  that  the  umbilicus  corresponds  to 
the  centre  of  the  cut.  Some  surgeons  prefer  an  incision 
along  the  outer  edge  of  the  left  rectus  muscle.  The 
viscus  is  then  slowly  pressed  out  of  the  wound.  The 
great  difficulty  is  with  the  gastro-splenic  omentum, 
which  has  to  be  divided  and  its  vessels  secured.  In 
drawing  out  the  spleen  there  is  much  risk  of  tearing 
the  splenic  vessels,  especially  the  vein.  Special  care 
has  to  be  taken  to  avoid  damage  to  the  pancreas.  The 
splenic  artery,  with  its  large  accompanying  vein,  lies 
in  the  lieno-renal  ligament,  in  contact  with  the  tail 
of  the  spleen  below. 

The  pancreas  lies  behind  the  stomach,  in    front 


Ghap.  xvii.]      The  Abdominal    Viscera.  359 

of  the  first  and  second  lumbar  vertebrae.  It  crosses 
the  middle  li.ie  0.1  a  level  with  a  point  about  3  inches 
above  the  umbilicus.  In  emaciated  subjects,  and  when 
the  stomach  and  colon  are  empty,  it  may  sometimes 
be  felt  on  deep  pressure.  It  Is  in  relation  with  many 
most  important  structures,  but  presents  little  of 
surgical  interest  (Figs.  47  and  48).  So  closely  is  it 
mixed  up  with  the  solar  plexus  that  this  structure  is 
necessarily  involved  in  any  operative  procedures  on  the 
head  and  neck.  It  has,  I  believe,  never  been  ruptured 
alo.ie,  and  it  could  scarcely  be  wounded  without  the 
wound  implicating  other  and  more  important  viscera. 
It  has  been  found  herniated  in  some  very  rare  cases  of 
diaphragmatic  hernia,  but  never  alone.  Its  duct  ends 
in  the  ampullated  extremity  of  the  common  bile  duct, 
and  through  it  septic  infections  of  the  duodenum  may 
spread  to  the  pancreas.  A  secondary  duct  may  be 
present.  It  opens  an  inch  nearer  the  pylorus  than 
the  main  duct. 

It  may  become  invaginated  into  the  intestine,  and 
portions  of  the  gland  have  sloughed  off  and  been  passed 
i.i  the  stools. 

The  common  bile  duct  in  its  second  stage  lies  between 
the  head  of  the  pancreas  and  the  duodenum.  It  thus 
happens  that  in  carcinoma  of  this  part  of  the  gland 
the  duct  may  become  entirely  occluded  and  jaundice 
result.  Or  the  duodenum  and  even  the  colon  may  be 
more  or  less  obstructed  by  pressure,  or  the  neighbouring 
vessels  be  closed.  Cancer  of  the  pylorus  may  spread  to 
the  head  of  the  pancreas  by  direct  extension.  The 
lymphatics  of  the  two  parts  also  freely  communicate. 

The  pancreas  lies  behind  the  lesser  sac  of  the  peri- 
toneum, its  anterior  surface  being  covered  by  the 
posterior  wall  of  the  sac.  It  lies  in  front  of  the  aorta, 
in  the  fork  between  the  cceliac  axis  above  and  the 
superior  mesenteric  artery  below.  The  portal  vein 
passes  upwards  behind  the  neck   of  the  gland. 

Certain  remarkable  cysts  are  sometimes  developed 
in  the  pancreas.  They  may  attain  great  size  and  nearly 
fill  the  abdomen. 


360  Surgical  Applied  Anatomy,  [dap.  xvii. 

The  Kidney. 

In  front. 

Right.  L    . 

Under  surface  of  liver.  -c,      ->        /  1^„a 

ci          ■,        ,     f  1      -,  fundus  of  stomach. 

Second  part  of  duodenum.  -^           -,.          , 

nnimenLBnt  nf  ^«r««  Descending  colon. 


Commencement  of  transverse 
colon.     Ascending-  colon. 


Pancreas. 


Externally.  -mr.  1  Externally. 

Liver.  JAJUliey.        (On  left  side)  Spleen. 


Behind. 

Lower  part  of  arch  of  diaphragm. 

Quadratus  lumborum.     Psoas. 

Last  rib  and  transverse  processes  of  upper  two  lumbar  vertebrae. 

The  kidneys  are  deeply  placed,  and  cannot  be  felt 
or  distinctly  identified  when  normal.  They  are  most 
accessible  to  pressure  at  the  outer  edge  of  the  erector 
spinas,  just  below  the  last  rib  (Fig.  50).  The  dulness 
of  the  right  kidney  merges  above  in  that  of 
the  liver,  while  on  the  left  side  it  is  impossible 
to  distinguish  between  the  dulness  of  the  kidney 
and  spleen.  The  right  kidney  lies  nearly  £  of  an  inch 
lower  down  than  does  the  left ;  but  even  the  lower 
end  of  the  right  gland  only  just  reaches  to  the  level 
of  the  umbilicus.  The  upper  end  of  the  left  kidney 
is  on  a  level  with  the  eleventh  dorsal  spine  behind, 
the  right  being  a  little  lower  (Figs.  41  and  49).  The 
inferior  extremity  of  the  left  gland  is  about  lj  inches 
from  the  iliac  crest,  that  of  the  right  about  1\  inches. 
The  kidney  lies  a  little  lower  in  the  female  than  in  the 
male.  In  many  instances  in  the  female  its  lower  end 
reaches  the  iliac  crest,  and  may  even  go  below  it.  Such 
positions  are  much  less  common  in  the  male.  A  vertical 
line  carried  upwards  from  the  middle  of  Poupart's 
ligament  has  one-third  of  the  kidney  to  its  outer  side 
and  two-thirds  to  its  inner  side.  The  hilum  lies  about 
2  inches  from  the  middle  line,  and  is  opposite  to  the  gap 
between  the  first  and  second  lumbar  spines.  The 
kidney  has  been  reached  by  the  finger  when  the  entire 


;6r 


•Fig.  49.— View  of  the  Kidneys,  etc.,  from  behind.  (Rudiuger). 

(i  Pharynx;  6,  innominate  artery ;  c,  subclavian  artery ;  ^oesophagus,  with  the 
aorta  and  tbnracic  duct  on  one  side  and  tbe  azygos  vein  on  tbe  <>tl 
luugs  :  r,  diaphragm:  {/.kidney;  ft,  on  peritoneum,  points  t«>  spermatic  \ 
crossed  by  ureter;   i.  os  innnminatuni  above  sacro-iliac-syncbondrnsis ;  j, 
psoas  :  k,  gluteus  metiiue  ;  l,  gluteus  maximus  ;  m,  rectum  and  bud,  bemorr* 
uoidal  artery. 


362  Surgical  Applied  Anatomy.  [Chap,  xvil 

hand  lias  been  introduced  into  the  rectum,  but  the 
procedure  has  failed  to  prove  of  much  use  in  diagnosis. 
A  skiagram  of  the  kidney  is  obscured  by  the  shadows 
of  the  last  rib  and  transverse  processes  of  the  two  upper 
lumbar  vertebrae. 

The  anterior  surface  is  but  slightly  covered  by 
peritoneum,  being  only  in  contact  with  that  membrane 
ia  such  parts  as  are  not  in  relation  with  the  cellular 
tissue  at  the  back  of  the  colon  and  at  the  back  of  the 
duodenum  or  pancreas.  The  external  border  is  more 
closely  in  connection  with  the  peritoneum,  while  the 
posterior  surface  is  quite  devoid  of  that  membrane 
(Figs.  47  and  49).  Crossing  the  posterior  surface  of 
the  kidney  obliquely  from  above  downwards  and  out- 
wards are  branches  of  the  last  dorsal  nerve  and  of  the 
first  lumbar  artery,  together  with  the  ilio-hypogastric 
and  ilio-inguinal  nerves.  Rupture  of  the  kidney  is 
more  often  recovered  from  than  is  a  like  lesion  of  any 
other  of  the  more  commonly  injured  abdominal  viscera. 
This  depends  upon  its  extensive  non-peritoneal  surface, 
whereby  the  extravasation  of  blood  and  urine  that 
follows  the  accident  is  very  often  entirely  extraperitoneal. 
The  gland  may  be  readily  wounded  from  behind  or  from 
the  loin,  without  the  peritoneum  being  injured.  When 
the  spine  is  much  bent  forwards,  the  kidney  lies  in  the 
angle  of  the  bend,  at  a  part  where  the  flexion  of  the 
column  is  the  most  acute.  In  extreme  flexion,  there- 
fore, of  the  spine,  it  may  be  squeezed  between  the  ilium 
and  the  lower  ribs.  Thus,  hematuria  is  not  uncommon 
after  injuries  to  the  back  associated  with  extreme 
bending  of  the  spine  forwards,  as  when  a  heavy  weight 
falls  upon  the  bowed  shoulders. 

The  kidney  is  embedded  in  a  large  quantity  of  loose 
fatty  tissue,  and  suppuration  extending  in  this  tissue 
constitutes  a  perinephritic  abscess.  Such  an  abscess 
may  be  due  either  to  disease  of  the  kidney  itself,  to 
affections  of  the  adjacent  parts  (spine,  colon,  etc.),  or 
to  injuries.  The  pus  is  at  first  in  front  of  the  quadratus 
lumborum,  anA  then  usually  makes  its  way  through 
that  muscle  or  through  the  lumbar  fascia.     It  then 


Chap,  xvn.]      The  Abdominal    Viscera.  363 

presents  itself  at  the  outer  edge  of  the  erector  spina?, 
having  passed  between  the  adjacent  borders  of  the 
external  oblique  and  latissimus  dorsi  muscles.  It  may, 
however,  spread  into  the  iliac  fossa,  or  extend  into  the 
pelvis  along  the  loose  connective  tissue  behind  the 
descending  colon  and  rectum,  or  open  into  the  colon 
or  bladder,  or  even  into  the  lung.  Most  rarely  of  all 
does  it  perforate  the  peritoneum.  Renal  abscess  usually 
opens  upon  the  non-peritoneal  surface  of  the  gland. 
It  may  open  into  the  adjacent  colon.  In  one  case  a 
renal  abscess,  due  to  stone,  made  its  way  from  the  right 
kidney  into  the  pyloric  end  of  the  stomach,  so  that  a 
communication  was  established  between  those  two 
organs.  The  perirenal  fat  is  of  much  surgical  import- 
ance, as  its  laxity  permits  of  a  ready  enucleation  of  the 
organ.  It  is  more  abundant  behind  than  in  front. 
When  this  tissue  has  been  destroyed  or  modified  by 
inflammation,  the  kidney  becomes  fixed,  and  its  removal 
a  matter  of  great  difficulty.  This  is  illustrated  by  the 
removal  of  a  large  tuberculous  kidney  which  has  been 
long  diseased. 

Movable  kidney. — The  kidney  is  fixed  in 
position  mainly  by  the  tension  of  the  peritoneum 
that  passes  over  it,  and  that  is  connected  with  the  fatty 
tissue  supporting  the  gland.  If  this  fatty  tissue  be 
absorbed  for  any  reason,  the  kidney  can  be  readily 
moved  about  and  displaced  in  the  subserous  tissue  ; 
the  peritoneum  at  the  same  time  becomes  lax,  and  the 
gland  by  its  own  weight  can  drag  still  further  upon  it. 
Moreover,  a  laxity  of  the  peritoneum  from  any  cause 
may  loosen  the  firm  connections  of  the  kidney,  and 
allow  the  organ  to  become  more  movable.  Thus,  the 
movable  kidney  is  often  met  with  in  badly  nourished 
subjects,  and  especially  in  those  who  have  become 
emaciated  by  disease.  It  is  far  more  common  in  women 
than  in  men.  In  the  former  sex  the  influence  of  preg- 
nancy appears  to  have  especial  effect,  acting,  probably, 
by  dragging  upon  the  peritoneum,  and  by  loosening 
its  connections,  as  well  as  by  inducing,  after  delivery, 
a   general  laxity   of   the   abdominal   walls.     The    right 


364  Surgical  Applied  Anatomy.  [Chap.  xvn. 

kidney  is  far  more  often  movable  than  is  the  left,  owing 
probably  to  the  displacing  influence  of  the  liver.  The 
abdominal  walls  undoubtedly  play  a  considerable  part 
in  maintaining  the  kidneys  in  position  by  keeping  the 
other  abdominal  viscera  steadily  compressed  against 
them.  The  upper  third  of  the  kidney  rests  on  the 
diaphragm,  and  with  every  breath  it  rises  and  falls 
a  little,  a  movement  which  must  be  considered  in  any 
operation  to  fix  the  kidney.  I  have  recorded  (in  con- 
junction with  Dr.  Maclagan)  three  cases  in  which  a 
movable  kidney  pressed  against  the  neck  of  the  gall 
bladder  and  obstructed  the  flow  of  bile.  The  movable 
kidney  can,  of  course,  only  be  moved  within  a  segment 
of  a  circle  whose  radius  corresponds  to  the  length  of 
the  renal  vessels,  and  yet  its  displacement  may  be 
considerable. 

The  dragging  pains  which  are  felt  with  a  movable 
kidney  are  due  to  a  stretching  of  the  renal  plexus, 
which  is  connected  with  the  solar  plexus  and  enters 
the  kidney  with  the  arteries.  The  kidney  receives  its 
nerve  supply  from  the  tenth,  eleventh,  twelfth  dorsal, 
and  first  lumbar  segments  of  the  spinal  cord  through 
the  small  and  lesser  splanchnics  (Head).  Pain  is  re- 
ferred along  the  sensory  nerves  derived  from  these 
segments. 

Abnormalities  of  the  kidney. — One,  or  less 
frequently  both,  kidneys  may  be  misplaced.  The  left 
is  more  often  out  of  place  than  the  right,  and  may  be 
found  over  the  sacro-iliac  synchondrosis,  or  the  promon- 
tory of  the  sacrum,  or  be  discovered  in  the  iliac  fossa 
or  pelvis.  The  misplaced  kidney  is  often  misshaped. 
The  kidney  may  exhibit  a  more  or  less  extreme  degree 
of  lobulation,  a  condition  present  in  the  newly  born. 
The  ureter  may  be  double. 

The  two  kidneys  may  be  fused.  "  The  lowest  degree 
of  fusion  is  seen  in  the  horse-shoe  kidney.  The  two 
kidneys  are  united  at  their  inferior  portions  by  a  flat, 
riband-like,  or  rounded  bridge  of  tissue,  which  crosses 
the  vertebral  column.  In  the  higher  degrees  the  two 
lateral  portions  approach  one  another  more  and  more 


Chap,  xvii.]      The  Abdominal    Viscera. 


365 


until  they  reach  the  highest  degree,  in  which  a  single 
disc-like  kidney,  lying  in  the  median  line,  and  provided 
with  a  double  or  single  calyx,  represents  complete  fusion  " 
(Rokitansky).  When  the  two  kidneys  are  united  by 
a  web  of  connective  tissue,  the  condition  is  no  bar  to 


EL. 


Fig.  50.— Showing  the  Relationships  of  the  Kidney  and  Colon  in  the  Lumbar 
Region  from  behind,  (Adapted  from  Merkel.) 

p.l.,  Lower  line  of  pleura  ;  XX,  eleventh  ril> ;  xu„  twelfth  rib  ;  12th  d.n.,  twelfth 
dorsal  nerve;  1st  Ln.,  llio-inguinal  and  ilio-bypogastric  nerves ;  a  b.  vortical 
line  representing  position  of  descending  colon  (desc.  c) ;  q.l..  quadratus  lum- 

f.  horuin;  b.s., erector  spina?;  peritoneum  (per  it.)  is  shown  reflected  from  the 
front  of  the  kidney  to  the  colun  on  the  right  side. 

operation.  There  may  be  an  entire  absence  of  one 
kidney.  The  single  kidney  may  be  lateral  or  median 
in  position.  Henry  Morris  gives  the  following  estimate 
of  the  frequency  of  these  abnormal  conditions.  Con- 
genital absence  or  extreme  atrophy  of  one  kidney  may 
be  expected  in  about  one  in  4,000  cases,  the  horse-shoe 


366  Surgical  Applied  Anatomy.  [Chap.  xvn. 

kidney  in  one  in  1,600,  and  the  single  fused  kidney 
in  one  in  8,000  cases. 

Operations  011  the  kidney. — (1)  Nephrotomy. 
Incision  into  the  kidney  for  exploration,  or  the  evacua- 
tion of  pus.  (2)  Nephrolithotomy.  Incision  into  the 
gland  for  the  removal  of  a  calculus.  (3)  Nephrectomy. 
Eemoval  of  the  entire  organ.  (4)  Nephroraphy.  The 
operation  of  securing  a  movable  kidney  in  its  normal 
position.  In  the  first,  second,  and  fourth  operations 
the  kidney  is  reached  through  the  loin  by  an  oblique 
incision,  such  as  is  used  in  colotomy  (page  345),  the 
cut,  however,  being  carried  a  little  farther  backwards. 
In  nephrectomy  a  like  incision  may  be  used.  The 
cut  is  carried  backwards  about  1  inch  over  the  erector 
spinas,  and  a  part  of  the  quadratus  lumborum  will 
probably  have  to  be  divided.  The  perinephritic  tissue 
is  opened  up,  and  the  gland  enucleated  from  the  capsule 
of  fat  in  which  it  lies.  In  some  instances  the  last  rib 
has  been  resected  to  obtain  more  space  for  the  operation. 
The  pleura  reaches  the  neck  of  the  twelfth  rib  and 
occasionally  it  descends  as  far  as  the  transverse  process 
of  the  first  lumbar  vertebra  (Fig.  50).  In  one  case 
the  twelfth  rib  was  rudimentary,  and  the  eleventh 
rib  was  removed  under  the  impression  that  it  was  the 
twelfth.     The  pleura  was  opened  and  death  ensued. 

When  the  kidney  is  free  from  its  fatty  capsule,  the 
vessels  at  the  hilum  are  secured  separately  by  ligatures. 
The  numerous  nerves  to  the  kidney  are  no  doubt  included 
with  the  vessels.  They  constitute  a  surgical  pedicle 
of  the  kidney.  At  the  hilum  the  vein  lies  in  front, 
the  artery  and  its  branches  next,  and  the  ureter  behind 
and  towards  the  lower  part.  The  artery  is  about  the 
size  of  the  brachial,  and  usually  divides  into  four,  five, 
or  six  branches  before  it  reaches  the  kidney.  This 
fact  must  be  borne  in  mind  if  the  structures  at  the 
hilum  are  separately  secured.  Some  of  these  branches 
constantly  enter  the  hilum  behind  the  ureter  and  are 
liable  to  injury  in  exploration  of  the  pelvis  of  the  kidney. 
The  vein  is  also  represented  at  the  hilum  by" three  or 
four  branches.     The  renal  artery  may  be  represented 


Chap,  xvii.]       The  Abdominal    Viscera.  367 

by  two,  three,  four,  or  even  five  vessels.  Some  may 
enter  the  upper  end  of  the  kidney  or  its  anterior  surface. 
In  removing  large  renal  tumours  an  abdominal  incision 
is  advised,  the  cut  being  made  either  along  the  corre- 
sponding semi-lunar  line,  and  on  a  level  with  the  diseased 
mass,  or  in  the  linea  alba.  The  abdominal  operation 
is  the  more  usual  one,  and  has  the  advantages  of  greater 
ease  and  rapidity  in  performance  and  gives  an  opportunity 
of  examining  the  condition  of  both  kidneys.  In 
chronically  inflamed  conditions  of  the  kidney — as,  for 
example,  in  long  standing  tuberculous  disease — the 
kidney  becomes  adherent,  and  on  the  right  side  is  apt 
to  become  closely  bound  clown  to  the  vena  cava.  Much 
care  is  needed  in  clearing  the  great  vein  when  so  adherent. 
In  removing  a  very  adherent  kidney  the  diaphragm 
has  been  torn. 

The  ureters  are  strong  tubes  about  15  inches  long, 
with  thick  muscular  Avails,  and  are  placed  entirely 
behind  the  peritoneum.  The  average  width  is  that 
of  a  goose-quill.  The  ureter  rests  from  above  down- 
wards upon  (1)  the  psoas  muscle  and  the  genito  crural 
nerve ;  (2)  the  common  iliac  vessels  on  the  left  side, 
and  the  external  iliac  vessels  on  the  right ;  (3)  after 
passing  downwards  on  the  internal  iliac  artery  it  then 
enters  the  posterior  false  ligament  of  the  bladder,  and  so 
reaches  the  bladder  wall.  In  the  female  it  passes  through 
the  base  of  the  broad  ligament,  where  the  uterine  artery 
loops  over  it  f  of  an  inch  from  the  necks  of  the  uterus. 
It  rests  on  the  roof  of  the  upper  part  of  the  vagina  before 
entering  the  bladder,  and  a  calculus  arrested  in  that 
stage  may  be  distinctly  felt.  The  narrowest  part  of 
the  tube  is  the  portion  within  the  bladder  walls,  and 
when  renal  calculi  pass  along  the  ureter  they  are  often 
arrested  at  this  point.  The  ureters  permit  of  great 
distension,  and  in  certain  cases  of  gradual  dilatation 
they  have  attained  a  width  equal  to  that  of  the  thumb 
and  even  of  the  small  intestine.  Several  cases  are 
recorded  of  rupture  of  the  ureter  from  external  violence. 
When  such  an  accident  occurs  a  large  urinary  collodion 
usually  forms  behind  the  peritoneum,  which,  leading 


368  Surgical  Applied  Anatomy.  [Chap.xvu. 

to    suppuration,    will    produce   a    fluctuating    tumour 
beneath  the  parietes. 

The  ureter  expands  in  the  hilum  of  the  kidney 
into  a  funnel-shaped  cavity — the  pelvis.  This  in 
turn  divides  into  the  calyces.  In  the  pelvis  or 
calyces  calculi  are  frequently  lodged.  The  calyces 
are  too  narrow  to  admit  an  exploring  finger.  The 
ureter  has  been  successfully  resected  and  sutured.  It 
is  supplied  by  nerves  from  the  renal  plexus  and  by 
vessels  from  the  renal,  inferior  vesical  and  sub-peritoneal 
plexus.  Impacted  calculi  have  been  removed  from 
the  ureter. 

The  nerve  supply  of  the  abdominal  viscera. 
— Some  account  has  already  been  given  of  these  nerves 
and  the  spinal  segments  from  which  they  are  derived 
(page  297).  The  abdominal  viscera  are  mainly  supplied 
by  the  sympathetic  system  through  a  series  of  remark- 
able plexuses.  The  most  important  of  these  is  the 
solar,  from  which  is  more  or  less  directly  derived  the 
nerve  supply  of  the  stomach,  liver,  spleen,  kidneys, 
suprarenal  capsules,  pancreas,  and  such  parts  of  the 
intestine  as  are  in  connection  with  the  superior  mesenteric 
artery.  The  solar  plexus  and  its  appendages  receive 
the  splanchnic  nerves  and  some  branches  from  the 
vagus,  while  communications  from  the  phrenic  go 
to  the  hepatic  and  suprarenal  plexuses.  Through 
these  nerves  the  calibre  of  the  blood-vessels  and  the 
amount  of  blood  in  the  abdomen  are  regulated.  They 
contain  not  only  sensory  fibres  for  the  abdominal  viscera 
but  constrictor  and  dilator  fibres  for  the  bowel.  It 
may  be  well  understood  that  an  impression  brought 
to  bear  upon  extensive  nerve  net-works  with  such  wide 
central  connections  and  with  such  important  relations 
would  produce  considerable  effects.  These  effects  we 
see  in  the  profound  collapse,  vomiting,  and  other  grave 
symptoms  that  attend  severe  injuries  to  the  viscera, 
and  especially  to  those  that  are  the  most  directly 
associated  with  these  large  plexuses.  The  descending 
colon  and  sigmoid  flexure  are  supplied  by  the  inferior 
mesenteric  plexus,  a  cord  that  has  but  an  indirect  con- 


chap,  xvii.]      The  Abdominal    Viscera.  369 

nection  with  the  solar  plexus;  and  this  fact  may  servo 
to  account  for  the  less  serious  symptoms  often  seen 
in  strangulation  of  the  colon  when  compared  with  a 
like  lesion  of  the  small  gut.  The  upper  part  of  the 
colon,  although  supplied  by  the  superior  mesenteric 
plexus,  is  only  supplied  by  that  part  of  it  that  is  most 
remote  from  the  great  centres,  and  it  is  a  conspicuous 
fact  that  the  nearer  the  lesion  is  to  the  stomach,  the 
graver,  other  things  being  equal,  are  the  nervous 
phenomena  produced.  It  would  appear  that  some  lesion 
of  these  nerve  plexuses  is  sometimes  active  in  producing 
a  remarkable  pigmentation  of  the  skin.  This  is  seen 
in  Addison's  disease,  a  disease  marked  by  a  general 
bronzing  of  the  surface,  and  usually  associated  with 
some  disintegration  of  the  suprarenal  capsules.  The 
very  direct  relation  of  these  bodies  to  the  solar  plexus 
is  well  known.  In  pregnancy  also,  in  abdominal  tuber- 
culosis, in  cancer  of  the  stomach,  and  in  liver  diseases, 
a  pigmentation  of  the  face  is  sometimes  seen,  that  may 
in  such  instances  be  probably  ascribed  to  a  disturbance 
of  the  great  abdominal  nerve  centres. 

In  some  diseases  of  the  liver  and  stomach  "  sympa- 
thetic "  pains  are  complained  of  between  the  shoulders 
or  about  the  inferior  angles  of  the  scapulae.  They  com- 
monly appear  some  distance  below  the  angle  of  the 
scapula.  The  nerves  for  the  stomach  are  derived  princi- 
pally from  the  seventh  and  eighth  and  those  for  the 
liver  from  the  eighth  and  ninth  spinal  segments.  The 
skin  areas  of  these  segments  may  become  tender  when 
the  organs  are  diseased  and  to  some  point  in  these  areas 
pain  is  referred  (Fig.  39).  The  shoulder  tip  pain  which 
often  accompanies  liver  disease  is  situated  in  the  area 
supplied  by  the  fourth  cervical  segment,  but  as  yet  no 
satisfactory  anatomical  explanation  has  been  offered  of 
this  symptom. 

There  would  seem  to  be  but  little  connection  between 
a  disease  in  the  sigmoid  flexure  and  a  pain  in  the  knee, 
yet  in  cases  of  cancer  in  the  flexure,  and  in  instances 
where  it  has  been  distended  with  faeces,  such  a  pain 
has  been  complained  of.     The  pain  is  conveyed  along 


37°  Surgical  Applied  Anatomy.  [Chap.  xvii. 

the  obturator  nerve,  which  lies  beneath  the  sigmoid 
flexure,  and  could  be  readily  pressed  upon  by  the  gut 
when  diseased. 

The   blood-vessels  of  the  abdomen. — Some 
of  the  visceral  branches''  of  the  abdominal  aorta  are  of 
large  size,  and  would  bleed  very  copiously  if  wounded. 
Thus,    the   cceliac   axis,    and   the   superior   mesenteric 
artery,  are  as  large  as  the  common  carotid  ;  the  splenic, 
hepatic,  and  renal  vessels   are  about  the  size  of  the 
brachial ;    while  the  largest  part  of  the  inferior  mesen- 
teric trunk  has  dimensions  equal  to  those  of  the  ulnar 
artery.     Aneurisms  of  the  aorta  are  especially  apt  to 
occur  at  the  cceliac  axis,   that  being  a  point  where  a 
number  of  large  branches  are  abruptly  given  off,  and 
where  the  course  of  the  circulation  undergoes  in  con- 
sequence a  sudden    deviation.     Although    two,  or   in 
some  places  three,  anastomotic  arches  occur  between  the 
branches  of  the  superior  mesenteric  artery  before  they 
form  a  final  net-work  in  the  bowel,  yet  embolism  of  a 
comparatively  small  branch  may  lead  to  gangrene  of 
the  gut  (Lockwood). 

When  it  is  remembered  that  the  lumbar  glands 
lie  about  the  vena  cava  and  iliac  veins,  it  will  be  under- 
stood that  great  enlargement  of  those  bodies  may  cause 
oedema  from  pressure. 

A  number  of  minute  but  most  important  anas- 
tomoses exist  between  some  of  the  visceral  branches 
of  the  abdominal  aorta  and  certain  of  the  vessels  supplied 
to  the  abdominal  parietes.  These  anastomoses  are 
situated  behind  the  peritoneum,  and  mostly  concern 
such  viscera  as  have  a  fair  surface  uncovered  Iby  that 
membrane.  The  visceral  branches  that  join  the  anasto- 
moses are  derived  from  the  hepatic,  renal,  and  supra- 
renal arteries,  and  from  the  vessels  supplying  the  lower 
part  of  the  duodenum,  the  pancreas,  the  csecum,  and  the 
ascending  and  descending  segments  of  the  colon.  The 
parietal  vessels  joining  with  the  above  are  derived  from 
the  phrenic,  lumbar,  ilio-lumbar,  lower  intercostal, 
epigastric,  and  circumflex  iliac  trunks.  In  a  case  de- 
tailed  by  Professor  Chiene  (Journ,   Anat.   and  Phys., 


Chap,  xvii]      The  Abdominal    Viscera.  371 

vol.  iii.)  the  coeliac  axis  and  mesenteric  vessels  were 
plugged,  but  blood  in  sufficient  amount  to  supply  the 
viscera  had  reached  the  branches  of  these  arteries  through 
their  parietal  communications.  Rutherford  .Morrison 
found  that  anastomotic  veins,  quite  as  big  as  the  radial, 
were  formed  between  the  omental  and  parietal  veins, 
when  he  brought  about  an  adhesion  between  the 
omentum  and  abdominal  wall  in  a  case  of  dropsy  due 
to  portal  obstruction.  The  anastomosis  gives  an 
anatomical  demonstration  of  the  value  of  local  blood- 
lettings and  of  counter-irritants  in  inflammatory 
affections  of  certain  of  the  viscera,  and  also  a  scientific 
basis  to  the  ancient  practice  of  poulticing  the  loin 
and  the  iliac  region  in  nephritis  and  in  inflammation 
about  the  caecum. 

Cases  have  been  recorded  of  communications, 
between  the  external  iliac  vein  and  the  portal  vein. 
These  have  generally  been  effected  by  the  deep 
epigastric  vein  joining  with  a  pervious  umbilical  vein 
in  the  vicinity  of  the  navel. 

Thoo'acic  duct. — Some  six  cases  of  wound  of 
this  duct  have  been  reported,  the  injury  being  usually 
a  stab.  In  each  case  lymph  and  chyle  in  large  quantities 
escaped  from  the  wound.  In  one  instance  the  duct  is 
said  to  have  been  injured  by  a  bullet  that  entered  just 
below  the  left  scapula,  since  from  the  wound  in  the 
integuments  large  quantities  of  lymph  escaped  freely. 
The  duct  has  been  found  to  have  been  obliterated,  and 
that,  too,  without  producing  any  marked  symptoms 
during  life.  It  has  been  cut  and  ligatured  during 
removal  of  glands  from  the  supra-clavicular  triangle, 
with  no  bad  result.  Mr.  Leaf  has  shown  that  the  thoracic 
duct  communicates  freely  with  the  azygos  veins  in  the 
posterior  mediastinum  and  with  the  lymphatic  vessels 
of  the  right  side  of  the  thorax  and  neck. 


372 
CHAPTER    XVIII. 

THE   PELVIS    AND    PERINEUM. 

The  mechanism  ©f  the  pelvis.  —  Besides 
forming  a  cavity  for  certain  viscera,  a  support  for  some 
abdominal  organs,  and  a  point  for  the  attachment 
of  the  lower  limb  and  of  many  muscles,  the  pelvis  serves 
to  transmit  the  weight  of  the  body  both  in  the  stand- 
ing and  sitting  postures.  The  transmission  is  effected 
through  two  arches,  one  available  for  the  erect  position, 
the  other  for  the  posture  when  sitting.  The  sacrum 
which  supports  the  spinal  column  is  the  centre  or  key- 
stone of  both  these  arches.  When  standing,  the  arch 
is  represented  by  the  sacrum,  the  sacro-iliac  synchon- 
droses, the  acetabula,  and  the  masses  of  bone  extending 
between  the  two  last-named  points.  If  all  other  parts 
of  the  pelvis  were  to  be  cut  away  but  these,  the  portions 
left  would  still  be  able  to  support  the  weight  of  the  body, 
and  would  represent  in  its  simplicity  the  arch  through 
which  that  weight  is  transmitted.  When  sitting  the 
arch  is  represented  by  the  sacrum,  the  sacro-iliac  synchon- 
droses, the  tubera  ischii,  and  the  strong  masses  of  bone 
that  extend  between  the  two  last-named  parts.  Morris 
terms  these  two  arches  the  femoro-sacral  and  the  ischio 
sacral.  On  examining  the  innominate  bone  it  will 
be  seen  that  its  thickest  and  strongest  parts  are  such 
as  are  situate  in  the  line  of  these.  "  When  very  con- 
siderable strength  is  requisite  in  an  arch,  it  is  continued 
into  a  ring  so  as  to  form  a  counter-arch,  or  what  is  called 
a  tie  is  made  to  connect  together  the  ends  of  the  arch, 
and  thus  to  prevent  them  from  starting  outwards. 
By  these  means  a  portion  of  the  superincumbent  weight 
is  conveyed  to  the  centre  of  the  counter-arch,  and  borne 
in  what  is  called  the  sine  of  the  arch.  The  body  and 
horizontal  rami  of  the  pubes  form  the  tie  or  counter- 
arch  of  the  femoro-sacral,  and  the  united  rami  of  the 
pubes  and  ischium  the  tie  of  the  ischio-sacral  arch. 
Thus  the  ties  of  both  arches  are  united  in  front  at  the 


chap,  xvin  i     The  Pelvis  and  Perineum.  373 

symphysis  pubis,  which,  like  the  sacrum  or  keystone, 
is  common  to  both  arches This  explains  how- 
it  is  that  so  much  strain  is  made  upon  the  symphysis 
when  any  increased  weight  has  to  be  supported  by  the 
pelvis,  as  in  pregnancy ;  why  there  is  such  powerlessness, 
with  inability  to  stand  or  sit,  in  cases  in  which  this  joint 
is  weakened  or  diseased ;  and  why  the  anterior  portion 
of  the  pelvis  yields  under  the  weight  of  the  body,  and 
becomes  deformed  in  rickets  and  mollities  ossium."  * 
The  pelvic  deformity  in  rickets,  it  may  be  here  observed, 
varies  greatly  according  to  the  age  at  which  the  disease 
sets  in,  and  the  usual  attitude  of  the  child  when  it 
becomes  affected.  The  deformity  sometimes  produced 
in  very  young  infants  has  been  ascribed  to  muscular 
contraction  (ilio-psoas,  erector  spina?,  gluteus  medius, 
etc.).  In  the  rickety  pelvis,  par  excellence,  the  two 
acetabula  approach  one  another,  the  anterior  part  of  the 
pelvis  yields,  so  that  the  symphysis  is  pushed  forward, 
and  the  cavity  becomes  greatly  narrowed  in  its  antero- 
posterior diameter.  In  severe  cases  the  anterior  arch 
may  practically  collapse,  and  the  horizontal  rami  of  the 
pubes  be  for  some  little  way  parallel  to  one  another. 

In  the  erect  attitude  the  pelvis  is  so  inclined  that 
the  plane  of  the  brim  of  the  true  pelvis  forms  with 
the  horizon  an  angle  of  from  60°  to  65° ;  the  base  of 
the  sacrum  is  about  3|  inches  above  the  upper  border 
of  the  symphysis,  while  the  tip  of  the  coccyx  is  a  little 
higher  than  its  lower  border.  The  centre  of  gravity 
of  the  whole  body  (adult)  is  at  a  spot  just  above  the 
sacro-lumbar  angle,  and  exactly  over  the  mid-point  of 
a  line  drawn  between  the  heads  of  the  femora.  The 
obliquity  of  the  pelvis  materially  assists  in  breaking 
shocks,  and  in  distributing  forces  applied  from  below 
throughout  the  pelvic  ring.  In  modifying  the  effect 
of  shocks,  also,  it  is  aided  by  the  arches  of  the  pelvis 
and  by  the  buffer-like  discs  of  cartilage  at  the  symphysis 
and  sacro-iliac  joints. 

Fractures    of  the    pelvis. — From    what    has 

*  Henry  Morris  on  "The  Joints,"  p.  116,  where  a  most  valu- 
able account  of  the  mechanism  of  the  pelvis  will  be  found 


374  Surgical  Applied  Anatomy.  [Chap,  xviii. 

been  already  said,  it  may  be  surmised  that  the  weakest 
parts  of  the  pelvis  are  at  the  symphysis  and  the  sacro- 
iliac joints.  The  bones  of  these  parts,  however,  are 
so  very  firmly  knit  together  by  powerful  ligaments 
that  it  is  very  rare  for  these  articulations  to  give  way, 
fracture  of  the  adjacent  bones  being  more  common. 
The  commonest  fracture  of  the  pelvis  is  in  the  weak 
counter  arch,  and  involves  the  rami  of  both  the  pubes 
and  the  ischium.  The  fracture  is  often  associated  with' 
some  tearing  of  ligaments  about  the  sacro-iliac  synchon- 
drosis, and  is  met  with  in  accidents  due  to  the  most 
varied  forms  of  violence.  This  last  remarkable  circum- 
stance is  thus  explained  by  Tillaux.  If  the  pelvis  be 
compressed  in  (a)  an  antero-posterior  direction,  the 
main  brunt  of  the  force  comes  upon  the  weak  counter 
arch,  which  fractures  from  direct  violence.  The  force, 
continuing,  tends  to  push  asunder  the  two  iliac  bones, 
and  so  cause  rupture  of  the  anterior  ligaments  at  the 
sacro-iliac  joint.  If  the  force  be  applied  (6)  trans- 
versely, the  two  acetabula  tend  to  be  pressed  towards 
one  another,  the  counter  arch  becomes  more  bent, 
and  ultimately  gives  way  by  indirect  violence.  The 
violence,  continuing,  forces  the  two  ilia  towards  one 
another,  the  strain  then  falls  upon  the  sacro-iliac 
synchondrosis,  and  the  posterior  ligaments  of  that 
joint  are  apt  to  yield,  or  portions  of  the  bone  adjacent 
to  the  joint  are  torn  away.  In  cases  of  falls,  when 
the  patient  alights  upon  the  feet  or  ischial  tuberosities, 
it  can  be  understood  how  in  many  instances  the  main 
arches  will  escape  injury  owing  to  their  great  strength, 
while  the  counter  arch  becomes  fractured.  Any  part 
of  the  pelvis,  including  the  sacrum,  may  be  broken 
by  well-localised  direct  violence.  More  or  less  of  the 
iliac  crest,  the  anterior  superior  and  posterior  superior 
spines,  have  been  knocked  off.  The  first-named  part 
may  be  separated  as  an  epiphysis.  It  joins  the  bone 
at  about  the  twenty-fourth  year.  In  one  case  the 
anterior  inferior  spinous  process  was  torn  off  by  the 
rectus  muscle  during  the  act  of  running  a  race.  The 
os    innominatum    has    been    broken    into    its    three 


Chap,  xvni.]  The  Pelvis  and  Perineum.  375 

anatomical  portions.  This  accident  cannot  take  place 
after  about  the  seventeenth  year,  since  by  that  time 
the  Y-shaped  cartilage  is  usually  fully  ossified,  and 
the  three  elementary  bones  are  fully  united.  Before 
such  consolidation  occurs  abscess  in  the  hip  joint  not 
very  (infrequently  makes  its  way  through  the  cartilage 
into  the  pelvis.  The  acetabulum  has  been  fractured, 
and  the  head  of  the  femur  driven  through  its  thinnest 
part  into  the  pelvis.  In  fractures  of  the  pubes  and 
ischium  the  bladder  has  been  torn  by  the  sharp 
fragments.  In  one  case  a  loose  piece  of  bone  that  had 
been  driven  into  the  bladder  became  the  nucleus  for 
a  stone.  The  urethra  and  vagina  also  have  been 
lacerated,  or  seriously  compressed  by  the  displaced 
bones.  In  fractures  of  the  sacrum  the  rectum  has 
been  torn,  or  has  been  so  compressed  by  the  lower 
fragment  (which  is  almost  always  carried  forwards) 
as  to  be  nearly  closed. 

Special  parts  of  the  pelvis.  Symphysis.— 
Separation  of  the  bones  at  the  symphysis  without 
fracture  has  occurred  from  severe  violence.  Malgaigne 
reports  three  cases  where  the  separation  was  brought 
about  by  muscular  violence  only,  by  extreme  action 
of  the  adductor  muscles  of  the  two  sides.  The  Sigaultean 
operation  consisted  in  dividing  the  symphysis  pubis 
in  cases  of  contracted  pelvis,  with  the  idea  of  obtaining 
more  room  during  labour,  and  of  so  avoiding  Caesarian 
section.  The  union  consists  of  fibro-cartilage  and  trans- 
verse peripheral  fibrous  bands.  It  varies  in  depth  from 
1^  to  1}  inches,  and  may  be  divided  subcutaneously 
when  the  bones  gape  quite  \  an  inch.  It  has  been  shown, 
however,  that  to  gain  \  an  inch  in  the  antero-posterior 
diameter  the  bones  must  be  separated  to  the  extent 
of  2  inches.  Such  a  separation  involves  laceration  of 
the  sacro-iliac  ligaments,  and  more  or  less  damage  to 
the  attachments  of  the  pelvic  viscera. 

The  sacro-iliac  synchondrosis  may  be  the  seat 
of  disease.  Normally,  there  is  no  movement  at  this 
joint,  but  when  the  ligaments  are  softened  by  disease, 
and  effusion  occurs  between  the  opposed  bones,  some 


376  Surgical  Applied  Anatomy.  [Chap.  xvm. 

movement  may  be  demonstrated.  As  this  joint  lies 
in  the  line  of  the  great  arches  of  the  pelvis,  it  follows 
that  when  inflamed,  much  pain  is  felt  in  the  part,  both 
when  the  patient  is  standing  and  when  sitting.  When 
abscess  forms  it  tends  to  come  forwards,  owing  to  the 
anterior  ligaments  being  less  dense  than  the  posterior. 
Having  reached  the  pelvic  aspect  of  the  joint,  the  pus 
may  occupy  the  iliac  fossa,  or  gain  the  ilio-psoas  sheath. 
Or  it  may  follow  the  lumbo-sacral  cord  and  great  sciatic 
nerve  and  point  in  the  thigh  behind  the  great  trochanter, 
or  it  may  be  guided  by  the  obturator  vessels  to  the  inner 
side  of  the  thyroid  foramen,  and  ultimately  appear  at 
the  inner  side  of  the  thigh.  The  abscess  may,  however, 
proceed  backwards,  and  point  over  the  posterior  aspect 
of  the  joint. 

The  nerve  relations  of  this  joint  are  important. 
It  is  supplied  by  the  superior  gluteal,  by  the  lumbo- 
sacral cord  and  the  first  sacral  nerve,  and  by  the  first  and 
second  posterior  sacral  nerves  (Morris).  The  lumbo- 
sacral cord  and  the  obturator  nerve  pass  over  the  front 
of  the  joint,  the  former  being  very  closely  connected 
with  the  articulation.  It  will  be  understood  from  these 
relations  that  in  the  sacro-iliac  disease  pain  is  felt  over 
the  sacral  region  (upper  sacral  nerves)  and  in  the  buttock 
(gluteal  nerve).  Much  pain  is  also  often  complained 
of  in  the  hip  or  knee-joint,  and  along  the  inner  part  of 
the  thigh  (obturator  nerve).  In  one  or  two  reported 
cases  there  has  been  severe  pain  in  the  calf  and  back 
of  the  thigh,  with  painful  twitchings  in  the  muscles 
of  those  parts  (lumbo-sacral  cord  and  connection  with 
great  sciatic  nerve).  Dislocation  of  the  sacrum  at  this 
joint  is  prevented  by  the  remarkable  double-wedge- 
shaped  outline  of  the  bone,  and  by  the  very  dense  liga- 
ments that  bind  it  in  its  place.  The  thick  end  of  the 
main  wedge  of  the  sacrum  is  in  front,  and  therefore 
the  strongest  ligaments  are  to  be  found  behind  the  bone, 
as  if  to  prevent  it  from  slipping  forwards,  or  from  be- 
coming rotated  forwards  on  its  transverse  axis. 

Trendelenburg 's  operation. — In  order  to  bring  the 
two  pubic  bones  and  the  deficient  soft  parts  together 


Chap,  xviii.]  The  Pelvis  and  Perineum.  377 

in  ectopia  vesicae,  Trendelenburg  divide.-;  the  sacro- 
iliac synchondroses  on  either  side.  The  knife  is  made 
to  cut  the  posterior  sacro-iliac  ligaments,  the  inter- 
osseous and  superior  ligaments,  and  the  interarticular 
cartilage.  The  operation,  which  has  been  very 
successful,  is  Limited  to  children  between  the  ages  of 
two  and  five.  The  distances  between  the  anterior 
superior  iliac  spines  has — in  a  child  aged  two  and  a-half 
years — been  lessened  2  inches  by  this  operation. 

Spina  bifida. — This  term  refers  to  certain  con- 
genital malformations  of  the  vertebral  canal  associated 
with  the  protrusion  of  some  of  its  contents  in  the  form 
of  a  fluid  tumour.  The  malformation  usually  consists 
in  an  absence  of  the  neural  arches  and  spines  of  certain 
of  the  vertebrae,  and  the  tumour  therefore  projects 
posteriorly.  Spina  bifida  is  most  common  in  the  lumbo- 
sacral region,  the  neural  arches  of  the  last  lumbar  and 
of  all  the  sacral  vertebrae  being  absent.  The  neural 
arches  close  first  in  the  dorsal  and  last  in  the  lumbo- 
sacral region.  Next  in  frequency  it  is  found  limited 
to  the  sacral  region.  It  is  rare  elsewhere.  (1)  The 
membranes  may  protrude  alone  (spinal  meningocele). 
(•2)  The  membranes  may  protrude  together  with  the 
spinal  cord  and  its  nerves  (meningo-myelocele).  (3)  The 
membranes  may  protrude  with  the  cord,  the  central 
canal  of  which  is  dilated,  so  as  to  form  a  sac  cavity 
(syringo-myelocele.)    (See  Fig.  80,  p.  546.) 

The  meningo-myelocele  is  the  most  common  form. 
The  first-named  variety  is  rare,  the  last-named  very  rare. 
When  the  cord  occupies  the  sac  it  usually  adheres  to 
its  posterior  wall,  the  nerves  running  transversely 
across  the  sac  to  reach  the  intervertebral  foramina. 
When  compressed,  the  cerebro-spinal  fluid  is  forced 
into  the  subarachnoid  spaces  at  the  base  of  the  brain, 
which  is  forced  upwards  against  the  anterior  fontanelle, 
where  its  impact  may  be  felt.  The  tumour  becomes 
enlarged  and  tense  when  the  child  cries.  The  distension 
of  the  cerebral  and  spinal  veins  forces  the  fluid  in  the 
direction  of  least  resistance. 

As  might  be  expected,  spina  bifida  is  very  commonly 


378  Surgical  Applied  Anatomy.  [Chap,  xv hi. 

associated  with  some  evidence  of  injury  to  the  nerves 
arising  from  the  lower  part  of  the  spinal  cord.  In  the 
majority  of  instances  certain  of  these  nerves  would 
appear  to  have  become  atrophied  through  pressure. 
In  some  cases  the  nerve  affection  takes  the  form  of  club- 
foot of  a  severe  grade.  In  other  instances  there  is  more 
or  less  complete  paralysis  of  the  lower  limbs,  bladder, 
and  rectum. 

"  The  anatomy  of  the  spina  bifida  assumes  a  primary 
defect  of  development  of  the  mesoblast,  from  which 
the  structures  closing  in  the  vertebral  furrow  are  de- 
veloped. After  the  closure  of  the  neural  furrow  it 
would  appear  that  the  processes  of  mesoblast,  which 
subsequently  insinuate  themselves  between  the  primi- 
tive spinal  cord  and  its  overlying  epiblast,  are  formed 
in  an  insufficient  degree  to  meet  and  combine  "  (Com- 
mittee of  the  Clinical  Society,  London,  1885). 

Sacro-coccygeal  tumours* — The  sacro-coccy- 
geal  region  is  very  often  the  seat  of  cod  genital  tumours, 
some  of  them  of  such  a  shape  as  to  form  "  human  tails  "  ; 
and  to  this  part  of  the  pelvis  has  also  been  found  attached 
a  third  lower  limb  leading  to  the  condition  known  as 
"  tripodism." 

Parasitic  foetuses  are  also  frequently  found  attached 
to  this  segment  of  the  spine.  In  many  of  the  instances 
of  attached  foetuses  the  two  individuals  have  been 
joined  together  at  this  part  of  the  column.  Some  of 
the  sacro-coccygeal  tumours  contain  epithelial  cysts 
and  fragments  of  skin,  muscle,  nerve,  bone,  cartilage, 
and  mucous  membrane.  These  strange  masses  spring 
from  the  anterior  part  of  the  coccyx,  between  it  and 
the  rectum.  By  some  they  are  supposed  to  arise  from 
Luschka's  gland,  by  others  (Sutton)  from  the  structures 
known  to  embryologists  as  the  post-anal  gut  and  the 
neurenteric  passage. 

The  sacro-coccyg-eal  joint  may  be  dislocated  or 
diseased.  In  either  affection  great  pain  is  kept  up  from 
the  frequent  movement  of  the  part  by  the  muscles 
attached  to  the  coccyx  (the  gluteus  maximns,  coccygeus, 
levator  ani,  and  sphincter).     In  the  luxation  the  bone 


chap .  x  v  1 1 1 .  ]  The  Pel  vis  a  nd  Per  ine  um.  379 

may  project  into  the  rectum,  and  thus  give  trouble. 
The  joint  and  the  parts  about  it  may  be  the  seat  of  such 
severe  neuralgia  ("  coccygodynia  ")  as  to  require  excision 
of  the  coccyx,  or  a  free  division  of  the  structures  that 
cover  it  behind.  The  joint  and  the  fibrous  tissue  about 
it  are  supplied  by  the  following  nerves:  the  posterior 
divisions  of  the  second,  third,  and  fourth  sacral,  and 
the  anterior  and  posterior  divisions  of  the  fifth  sacral 
and  coccygeal.  In  old  age  the  coccyx  becomes  ossified 
to  the  sacrum. 

The  tliioiiiest  pints  of  the  os  iimoiiiiiiaftiiii 
are  at  the  bottom  of  the  acetabulum,  and  in  the  hollow 
of  the  wing  of  the  ilium.  In  the  latter  situation  the 
bone  has  been  successfully  trephined  for  iliac  abscess. 

The  fl»or  of  the  pelvis  and  the  pelvic  fascia. 
— The  outlet  of  the  bony  pelvis  is  occupied  in  the  recent 
state  with  the  following  structures  from  behind  for- 
wards :  the  pyriformis,  the  sacro-sciatic  ligaments/ 
the  coccygeus,  the  levator  ani,  and  the  triangular 
ligament  of  the  urethra.  These  form  the  floor  of  the 
pelvis.  The  three  structures  last  named  serve  to 
separate  the  pelvic  cavity  from  the  perineum. 

The  Avails  and  floor  of  the  pelvis  are  lined  by  a  fascia, 
the  pelvic  fascia,  of  which  a  brief  general  description 
may  be  given.  This  fascia  is  divided  into  two  distinct 
parts,  a  parietal  layer  and  a  visceral  layer.  (1)  The 
parietal  layer  begins  at  the  brim  of  the  true  ]  elvis, 
to  which  it  is  attached.  From  this  attachment  it  passes 
down  along  the  pelvic  wall,  forming  a  lining  for  that 
part,  covering  in  the  obturator  interims  muscle,  and 
becoming  adherent  below  to  the  rami  of  the  pubes 
and  ischium,  and  to  the  tuber  ischii.  More  posteriorly 
it  gives  a  thin  covering  to  the  pyriformis  muscle.  (2) 
The  visceral  layer  comes  off  from  the  parietal  along 
a  line  running  from  the  lower  part  of  the  symphysis 
pubis  to  the  ischial  spine.  This  line  is  known  as  the 
white  line,  and  corresponds  to  the  origin  of  the  levator 
ani  from  the  pelvic  fascia. 

Starting  from  this  line  the  visceral  layer  passes  down 
into  the  pelvis  on  the  abdominal  surface  of  the  levator 


380  Surgical  Applied  Anatomy,   chap,  xviii. 

ani,  and  attaches  itself  to  all  the  pelvic  viscera  with 
which  it  comes  in  contact,  forming  fibrous  expansions 
or  "  ligaments,"  that  serve  to  hold  the  viscera  in  place. 
Were  there  no  pelvic  viscera,  this  layer  of  the  fascia 
would  be  continued  evenly  across  the  pelvic  floor  from 
one  side  to  the  other,  just  as  the  subperitoneal  fascia 
is  continued  over  the  under  surface  of  the  diaphragm. 
Having  given  "  reflections "  to  the  pelvic  organs  the 
visceral  layer  passes  on,  and,  covering  the  opposite 
levator  muscle,  ends  at  the  opposite  white  line.  This 
visceral  layer  is  usually  known  as  the  recto-vesical  fascia. 

As  regards  the  parietal  division,  it  will  be  seen  that 
that  part  of  it  above  the  origin  of  the  visceral  layer 
{i.e.,  above  the  white  line)  is  in  the  pelvic  cavity,  while 
that  part  below  the  line  is  in  the  perineum.  To  this 
lower  segment  the  name  obturator  fascia  is  commonly 
given.  Now,  the  peritoneum  lines  some  part  of  the 
pelvic  floor,  and  covers  a  great  part  of  the  pelvic 
viscera.  Between  this  peritoneum  and  the  visceral 
layer  of  the  pelvic  fascia  is  a  good  deal  of  loose 
connective  tissue.  Inflammation  may  be  set  up  in 
this  tissue,  may  spread  readily  in  it,  and  may  of  course 
lead  to  suppuration.  Such  suppuration  will  be  limited 
to  the  pelvic  cavity,  and  will  be  hindered  from  escaping 
from  that  cavity  by  the  pelvic  fascia.  Inflammations 
of  any  extent  so  located  are  included  under  the  term 
pelvic  cellulitis.  Suppuration,  therefore,  above  the 
visceral  layer  of  the  pelvic  fascia  will  be  limited  to  the 
pelvic  cavity,  while  that  below  the  fascia  will  be  limited 
to  the  perineum,  to  either  the  urethral  or  the  anal 
segment  of  that  district.  Thus  it  will  be  seen  that  the 
pelvic  fascia  is  of  much  surgical  importance.  Wounds 
through  the  perineum  that  involve  this  fascia  will  be 
serious,  in  that  they  will  open  up  the  loose  tissue  on  the 
pelvic  aspect  of  the  fascia  in  which  inflammation  so 
readily  spreads,  while  unless  the  fascia  be  wounded 
the  pelvic  cavity  cannot  be  said  to  have  been  opened. 

The  fascia  is  so  reflected  upon  the  viscera  that  certain 
parts  of  them  are  excluded  by  the  attachments  of  the 
membrane  from  the  pelvic  cavity.     The  parts  so  excluded 


Chap,  xviii.]  The  Pelvis  and  Perineum.  381 

are  the  following  :  the  prostate,  the  neck  of  the  bladder, 
all  that  part  of  the  base  of  the  bladder  that  is  between 
the  seminal  vesicles,  the  seminal  vesicles  themselves, 
and  about  the  last  %\  or  3  inches  of  the  rectum.  On 
the  side  of  the  rectum  the  fascia  reaches  the  level  of  a 
line  drawn  from  the  top  of  the  seminal  vesicles  to  the 
middle  of  the  fifth  piece  of  the  sacrum.  In  the  middle 
line  it  reaches  a  point  some  little  way  below  the  recto- 
vesical cul-de-sac  of  the  peritoneum.  These  excluded 
portions  of  the  various  viscera  may  be  wounded  without 
the  pelvic  cavity  being  opened  up,  and  suppuration 
spreading  from  them  would  tend  to  spread  towards 
the  perineum,  and  not  into  the  pelvis.  Pelvic  cellulitis, 
to  use  the  term  in  the  strict  sense,  means  inflammation 
of  the  connective  tissue  between  the  pelvic  fascia  and 
the  peritoneum.*  This  connective  tissue  is  chiefly 
situated  between  the  anterior  wall  of  the  bladder  and 
the  pelvis,  about  the  base  and  neck  of  the  bladder, 
between  the  latter  viscus  and  the  rectum  ;  and  in  the 
female,  between  the  layers  of  the  broad  ligament  and 
about  the  lower  part  of  the  uterus  and  commencement 
of  the  vagina.  All  this  connective  tissue  is  continuous, 
and  inflammation  in  one  part  of  it  may  spread  to  the 
other  parts.  In  women  the  mischief  is  often  found 
between  the  folds  of  the  broad  ligament,  or  in  the  hollow 
between  the  uterus  and  the  rectum.  As  may  be  sup- 
posed, the  abscess  formed  in  such  cases  tends  to  mount 
up  in  the  pelvis,  being  unable  to  escape  below,  and 
usually  points  in  the  inguinal  region,  or  in  the  supra- 
pubic region,  having  spread  along  the  obliterated  hypo- 
gastric artery.  It  may,  however,  open  into  one  of  the 
pelvic  viscera  or  into  the  peritoneum,  but  both  these 
terminations  are  rare.  Out  of  thirty-seven  cases  of 
puerperal  pelvic  cellulitis  with  suppuration,  twenty- 
four  burst  externally,  and  for  the  most  part  in  the 
inguinal  region  (McClintock). 

*  Clinically  the  term  pelvic  cellulitis  includes  also  pelvic 
peritonitis,  and  often  inflammation  of  one  or  other  of  the  viscera. 
Indeed,  many  so-called  cases  of  pelvic  cellulitis  are  examples  of 
localised  pelvic  peritonitis  with  or  without  suppuration. 


382  Surgical  Applied  Anatomy.  [Chap,  xviii. 

It  should  be  borne  in  mind  that  the  blood-vessels 
of  the  pelvis  are  placed  on  the  peritoneal  aspect  of  the 
fascia.  The  branches  of  the  internal  iliac  artery,  there- 
fore, that  leave  the  pelvis,  escape  by  piercing  that 
membrane.  The  obturator  artery  is  an  exception  to 
this  rule,  since  it  passes  over  the  upper  border  of  the 
parietal  pelvic  fascia  (Cunningham).  The  nerves  in 
the  pelvis  lie  behind  or  outside  the  fascia,  and,  therefore, 
the  pelvic  vessels  and  the  pelvic  nerves  are,  excepting 
the  obturator,  separated  from  one  another  by  this 
layer  of  tissue. 

The  male  perineum.  —  The  perineum  is  a 
lozenge-shaped  space  bounded  by  the  symphysis,  the 
rami  of  the  pubes  and  the  ischia,  the  ischial  tuberosities, 
the  great  sacro-sciatic  ligaments,  the  edges  of  the  two 
great  gluteal  muscles,  and  the  coccyx.  A  transverse 
lLie  drawn  across  the  space  between  the  anterior  ex- 
tremities of  the  tubera  ischii,  and  just  in  front  of  the 
anus,  divides  the  perineum  into  two  parts.  The  anterior 
part  forms  nearly  an  equilateral  triangle,  measuring 
about  3j  inches  on  all  sides.  It  is  called  the  urethral 
triangle.  The  posterior  part  is  also  somewhat  triangular, 
contains  the  rectum  and  ischio-rectal  fossa,  and  is  called 
the  anal  triangle.  The  whole  space  measures  about  3  J 
inches  from  side  to  side,  and  about  4  inches  from  before 
backwards  in  the  middle  line.  The  average  antero- 
posterior diameter  of  the  pelvic  outlet  in  the  male  aver- 
ages 2>\  inches.  This  measurement  in  the  undissected 
subject  is  increased  to  4  inches  by  the  curving  of  the 
surface.  The  average  transverse  diameter  of  the  male 
pelvic  outlet  is  3^  inches,  and  corresponds  to  the  measure- 
ment of  the  perineum  above  given. 

The  bony  framework  of  the  perineum  can  be  felt 
more  or  less  distinctly  all  round,  and  in  thin  subjects 
the  great  sacro-sciatic  ligaments  can  be  made  out  beneath 
the  great  gluteal  muscle.  The  anus  is  in  the  middle 
line  between  the  tubera  ischii,  its  centre  being  about  l|- 
inches  from  the  tip  of  the  coccyx.  The  raphe,  a  central 
mark  or  ridge  in  the  skin,  can  be  followed  from  the  anus 
along  the  middle  line  of  the  perineum,  scrotum,  and 


chap,  xviii.]  The  Pelvis  and  Perineum. 


33; 


penis.  No  vessels  cross  this  line,  and,  therefore,  in 
making  incisions  into  the  perineum  this  line  is  always 
chosen   when   possible.     In   the    middle   line,    midway 


Fig.  51.— The  Male  Perineum.     (After  Riidir-ger.) 

a,  Gluteus  niaxinms ;  b,  senii-tendinosus  and  biceps;  c,  adductor  magnus:  d, 
gracilis;  t,  piriformis:  f\, obturator interims;  </,  quadratus  femoris;  /(,  leva- 
tor ani ;  i,  external  sphincter;  j,  accelerator  urinse;  A\  erector  penis;  /, 
transversus  perinei ;  l.  great  sciatic  nerve  ;  '2,  external  bsemorrboidal  vessels 
and  nerve;  3,  superficial  perineal  vessels  and  nerves;  4,  pudic  nerve  (.can 
and  pudic  artery  ;  5,  pudendal  branch  of  small  sciatic  nerve. 

between  the  centre  of  the  anus  and  the  spot  where  the 
scrotum  joins  the  perineum,  is  the  central  point  of  the 
perineum.  The  two  transverse  perineal  muscles,  the 
accelerator  urinse  and  the  sphincter  ani   meet  at  this 


384  Surgical  Applied  Anatomy.  [Chap,  xviii. 

point,  which  also  corresponds  to  the  centre  of  the  inferior 
edge  of  the  triangular  ligament.  The  bulb  is  just  in 
front  of  it,  as  is  also  the  artery  to  the  bulb,  and  in  litho- 
tomy, therefore,  the  incision  should  never  commence  in 
front  of  this  spot. 

The  perineal  space  is  separated  from  the  pelvic  cavity 
by  the  levator  ani  muscles  and  recto-vesical  fascia, 
as  already  mentioned.  The  depth  of  the  perineum 
means  the  distance  between  the  skin  and  the  pelvic 
floor.  This  depth  depends,  to  a  great  extent,  upon  the 
amount  of  fat  under  the  integument.  It  varies  con- 
siderably in  different  parts,  measuring  from  2  to  3  inches 
in  the  hinder  and  outer  parts  of  the  perineum,  and  less 
than  1  inch  in  the  anterior  parts  of  the  space. 

The  iscliio-rectal  fossa  is  of  pyramidal  shape, 
its  apex  being  at  the  white  line,  and  its  base  being 
formed  by  the  skin  between  the  anus  and  the  ischial 
tuberosities.  It  measures  about  2  inches  from  before 
back,  1  inch  from  side  to  side,  and  is  between  2  and  3 
inches  in  depth.  Its  boundaries  are  :  on  the  outer  side, 
the  obturator  internus  muscle,  covered  by  the  parietal 
layer  of  the  pelvic  fascia  ;  on  the  inner  side,  the  levator 
ani,  covered  by  the  anal  fascia  ;  in  front,  the  base  of  the 
triangular  ligament  and  the  transversus  perinei  muscle  ; 
and  behind,  the  gluteus  maximus,  great  sacro-sciatic 
ligament,  and  coccygeus.  The  pudic  vessels  and  nerves 
are  on  the  outer  wall,  embedded  in  the  fascia  over  the, 
obturator  muscle,  and  are  placed  about  1\  inches  above 
the  lower  border  of  the  tubera  ischii. 

The  part  of  the  rectum  which  occupies  the  space 
between  the  two  fossae  is  supported  by  the  levatores 
ani,  external  sphincter,  and  recto-vesical  fascia.  Its 
lateral  wall  is  exposed  for  a  distance  of  nearly  3  inches, 
its  posterior  wall  for  about  1  inch  (Quain).  The  fossa 
is  occupied  by  a  mass  of  fat  which  affords  to  the  rectum 
the  support  of  an  elastic  cushion.  This  fatty  tissue  is 
badly  supplied  with  blood,  and  this  fact,  in  addition  to 
the  dependent  situation  of  the  part,  and  its  exposure 
when  the  patient  sits  upon  damp,  cold  seats,  etc.,  leads 
to  abscess  being  very  frequent  in  the  space  (ischio-rectal 


Ch^p.  xviii.]  The  Pelvis  and  Perineum.  385 

abscess).  These  abscesses  are  hemmed  in  on  all  sides, 
soon  fill  the  fossa,  and  then  tend  to  discharge  themselves 
in  the  two  directions  where  the  resistance  is  least,  viz., 
through  the  skin  and  through  the  wall  of  the  rectum. 
When  this  double  discharge  of  the  abscess  has  taken 
place,  a  complete  fistula  in  ano  is  established.  It  is  well 
to  note  that  in  all  fistidce  in  ano  the  opening  into  the 
rectum  is  nearly  always  within  \  an  inch  of  the  anus. 
An  opening  into  the  bowel  higher  up  is  resisted  by  the 
attachment  of  the  levator  ani,  by  the  anal  fascia  and  by 
the  recto-vesical  fascia. 

Crossing  the  space  obliquely  from  its  hinder  part 
to  the  anus  are  the  external  haemorrhoidal  vessels  and 
nerves ;  crossing  the  anterior  and  outer  corner  of  the 
fossa  are  the  perineal  vessels  and  nerves,  and  about  the 
posterior  border  of  the  space  are  the  fourth  sacral  nerve 
and  some  branches  of  the  small  sciatic  nerve.  It  will 
be  readily  understood,  therefore,  that  ischio-rectal 
abscesses  are  associated  usually  with  extreme  suffering 
until  they  are  relieved.  The  most  severe  pain  is  probably 
due  to  the  stretching  of  the  external  haemorrhoidal 
nerve  by  the  abscess  as  it  progresses  towards  the  surface. 
In  opening  an  abscess  in  the  fossa  the  main  structures 
to  avoid  are  the  rectum,  the  pudic  and  external  haemor- 
rhoidal vessels. 

Anus. — {See  paragraph  on  the  Kectum.) 

The  urethral  triangle. — The  skin  of  the  peri- 
neum between  the  anus  and  the  scrotum  is  thin,  and 
shows  very  readily  any  extravasations  of  blood  that 
may  form  beneath  it.  The  superficial  fascia  is  divided 
into  two  layers,  of  which  the  more  superficial  is  quite 
unimportant,  and  contains  what  little  subcutaneous 
fat  exists  in  this  part. 

The  deeper  layer,  known  as  the  perineal  fascia  or 
fascia  of  Colles,  is  attached  on  either  side  to  the  rami 
of  the  pubes  and  ischium,  and  behind  to  the  base  of 
the  triangular  ligament.  In  front  it  becomes  continuous 
with  the  dartos  tissue.  This  fascia,  therefore,  by  its 
attachments  forms  with  the  triangular  ligament'a  well- 
isolated   aponeurotic  space,   containing  the   bulb   with 


386  Surgical  Applied  Anatomy-.  [ChaP.  xvm. 

all  that  part  of  the  spongy  urethra  between  the 
triangular  ligament  and  the  attachment  of  the  scrotum, 
the  penile  muscles,  the  transverse  perineal  muscles, 
vessels,  and  nerves,  and  the  perineal  vessels  and  nerves. 
When  extravasation  of  urine  follows  upon  a  rupture 
of  the  part  of  the  urethra  above  named,  the  course  of 
the  escaping  fluid  is  directed  by  the  fascia  of  Colles. 
It  fills  the  aponeurotic  space.  It  is  unable  to  gain  the 
ischio-rectal  fossa  on  account  of  the  attachment  of  the 
fascia  to  the  triangular  ligament.  The  lateral  attach- 
ments of  this  membrane  prevent  the  urine  from  passing 
into  the  thighs.  It  is,  therefore,  guided  into  the  scrotum, 
and  there  finds  itself  beneath  the  dartos  tissue.  It 
distends  the  scrotal  tissues,  and  then  mounts  up  on  to  the 
abdomen  through  the  gap  left  between  the  symphysis 
pubis  and  pubic  spine.  It  must  be  remembered 
that  the  fascia  of  Colles,  the  dartos  tissue,  and  the 
deeper  layer  of  the  superficial  fascia  of  the  abdomen, 
are  continuous,  and  merely  represent  different  parts 
of  the  same  structure.  Pus  or  blood  within  this  aponeu- 
rotic space  would  follow  the  same  course  if  the  effusion 
were  extensive  enough.  The  pain  occasioned  by  such 
effusion  can  be  understood  when  it  is  noted  that  the 
three  chief  sensory  nerves  of  this  region  (the  three  long 
scrotal  nerves)  are  included  within  the  space. 

The  triangular  iigainciat.  has  a  depth  of  about 
\\  inches  in  the  middle  line,  and  is  formed  of  two  layers, 
of  which  the  posterior  is  derived  from  the  pelvic  fascia. 
The  membranous  urethra,  .surrounded  by  the  compressor 
urethrae,  lies  between  the  two  layers,  and  runs  about 
1  inch  below  the  symphysis,  and  about  f  of  an  inch 
above  the  central  point  of  the  perineum.  The  artery 
to  the  bulb  passes  inwards  between  the  two  layers  about 
\  an  inch  above  the  base  of  the  ligament  and  1^  inches  in 
front  of  the  anus.  The  dorsal  vein  and  the  terminal 
part  of  the  pudic  artery  and  nerve  pierce  the  anterior 
layer  of  the  ligament  about  \  an  inch  below  the  sym- 
physis. In  uncomplicated  rupture  of  the  membranous 
urethra,  the  urine  extravasated  would  be  limited  to 
the  space   between  the  layers  of  the  ligament,   until 


chap,  xviii.]  The  Pelvis  and  Perineum.  387 

subsequent  suppuration  had  made  a  way  for  it  to  escape. 
When  extravasation  occurs  behind  the  triangular 
ligament,  the  effusion  barely  escapes  the  pelvic  cavity, 
and  usually  by  following  the  rectum  gains  the  anal  part 
of  the  perineum. 

Just  beyond  the  triangular  ligament  is  the  prostate, 
surrounded  by  its  capsule,  and  the  prostatic  venous 
plexus.  In  dissecting  down  from  the  surface  to  the 
prostate,  we  meet,  as  Cunningham  has  well  pointed 
out,  alternate  strata  of  fascial  and  muscular  tissue, 
forming  seven  layers  in  all,  viz.  :  (1)  Superficial  fascia  ; 
(2)  superficial  perineal  muscles  ;  (3)  triangular  ligament 
(ant.  layer) ;  (4)  compressor  urethral  muscle  ;  (5)  tri- 
angular ligament  (post,  layer) ;  (6)  levator  ani  muscle  ; 
(7)  capsule  of  prostate. 

Stone  in  the  bladder. — Stones  of  the  bladder 
which  were  formerly  removed  by  a  perineal  incision 
are  now  commonly  crushed  and  washed  out  through 
the  urethra  by  the  operation  of  litholapaxy.  This 
operation  is  carried  out  readily  even  in  male  children. 
If  too  large  for  crushing,  the  supra-pubic  operation 
is  performed  to  give  sufficient  room  for  extraction. 
Although  the  perineal  operations  are  now  but  very 
rarely  performed,  a  description  of  the  parts  involved 
helps  to  give  a  proper  conception  of  their  important 
anatomical  relationships. 

Lateral  lithotomy. — The  first  incision,  2  or 
3  inches  in  length,  is  commenced  just  to  the  left 
of  the  middle  line  and  just  behind  the  central  point  of 
the  perineum,  i.e.,  about  \\  inches  in  front  of  the  anus. 
The  incision  is  carried  downwards  and  outwards  into 
the  left  ischio-rectal  fossa,  and  ends  at  a  point  between  the 
tuber  ischii  and  posterior  part  of  the  anus,  and  one-third 
nearer  to  the  tuberosity  than  to  the  gut.  In  the  early 
part  of  this  incision  the  staff  may  just  be  touched,  as  it 
lies  in  the  membranous  urethra,  the  incision  becoming 
more  and  more  shallow  as  the  knife  is  withdrawn.  The 
parts  cut  in  the  first  incision  are  :  (1)  Skin  and  super- 
ficial fascia  ;  (2)  transverse  perineal  muscle,  artery  and 
nerve ;   (3)   the  lower  edge  of  the  anterior  layer  of  the 


388  Surgical  Applied  Anatomy.  [Chap. xvm. 

triangular  ligament ;    (4)    the  external  hsemorrhoidal 
vessel  and  nerves.     (Figs.  51  and  52.) 

In  the  second  incision  the  knife,  guided  by  the  fore- 
finger of  the  left  hand,  is  passed  upwards  behind  the 
triangular  ligament,  is  engaged  in  the  groove  on  the 
staff  as  it  lies  in  the  membranous  urethra,  and  then, 
having  its  edge  turned  towards  the  left  tuber  ischii,  is 
steadily  carried  along  the  groove  into  the  bladder.  In 
this  incision  the  parts  divided  are  :  (l)  Membranous 
and  prostatic  portions  of  urethra  ;  (2)  posterior  layer 
of  triangular  ligament ;  (3)  compressor  urethrae  ;  (4) 
anterior  fibres  of  levator  ani  and  left  lateral  lobe  of 
prostate.  The  finger  is  then  introduced  along  the  staff 
into  the  bladder,  the  staff  is  removed,  and,  the  forceps 
being  inserted,  the  stone  is  extracted,  traction  being 
made  in  the  proper  axis  of  the  pelvis. 

Parts  that  may  be  wounded. — (a)  In  the  first  in- 
cision :  (1)  the  bulb,  or  the  artery  of  the  bulb.  These 
parts  can  be  avoided  by  commencing  the  incision  well 
behind  the  "  central  point,"  and  by  causing  the  holder 
of  the  staff  to  draw  it,  the  scrotum,  and  the  penis  well  up. 
The  staff  should  be  held  as  close  up  under  the  pubes  as 
possible.  The  bulb  is  very  small  in  children,  large  in 
adults,  and  largest  in  old  men.  (2)  The  rectum  may 
be  cut  if  much  distended,  or  if  the  incision  be  made  too 
vertical  or  carried  too  far  back.  In  all  cases  the  gut 
should  be  well  emptied  by  enema  before  the  operation. 
(3)  The  pudic  vessels  can  hardly  be  wounded  unless  the 
incision  is  very  carelessly  made,  and  the  knife  carried 
almost  against  the  bone  as  it  is  being  withdrawn,  (b)  In 
the  second  incision  the  knife  may  be  passed  beyond  the 
prostate,  and  may  so  incise  the  visceral  layer  of  the  pelvic 
fascia  as  to  open  up  the  pelvic  cavity.  It  will  be  under- 
stood that  the  lateral  lobe  of  the  prostate  may  be  cut 
freely  without  this  cavity  being  endangered.  The 
gland  is  enveloped  by  the  pelvic  fascia,  but  the  incision 
made  into  the  prostate  is  well  below  the  superior  reflection 
of  the  membrane.  The  incision  in  the  neck  of  the 
bladder,  therefore,  must  be  strictly  limited  to  the  prostate. 
The  prostatic  plexus  of  veins  cannot  avoid  being  wounded. 


Chap,  xviii.]  The  Pelv.-s  and  Perineum.  389 

The  left  ejaculatory  duct  would  be  cut  if  the  prostatic 
incision  were  carried  too  far  backwards. 

In  children  the  pelvis  is  relatively  narrower  than 
in  the  adult,  the  bladder  is  more  an  abdominal  than 
a  pelvic  organ,  and  the  neck  of  the  bladder,  therefore, 
is  high  up.  The  viscus,  moreover,  is  very  movable, 
and  has  less  substantial  attachments  than  has  the 
adult's  bladder.  It  thus  happens  that  in  forcing  the 
finger  into  the  bladder  after  the  second  incision,  the 
viscus  has  actually  been  torn  away  from  the  urethra. 
In  children  the  prostate  is  rudimentary,  and  thus  more 
of  the  actual  neck  of  the  bladder  itself  has  to  be  cut. 
From  the  small  size  of  this  gland,  also,  it  happens  that 
in  some  cases  the  knife  has  passed  too  far  beyond  the 
prostatic  area,  and  has  opened  up  the  pelvic  fascia.  In 
children  also  the  peritoneum  descends  lower  on  the 
posterior  surface  of  the  bladder,  and  may  be  wounded 
by  a  careless  operator. 

Median  lithotomy.  —  In  this  operation  the 
knife  is  entered  in  the  middle  line,  just  in  front  of  the 
anus.  The  staff  has  a  central  groove,  and  the  point  of 
the  knife  should  hit  the  instrument  as  near  as  possible 
to  the  apex  of  the  prostate.  As  the  knife  is  withdrawn 
the  whole  of  the  membranous  urethra  is  incised,  and 
a  wound  made  in  the  median  raphe  of  about  1^  inches 
in  length.  The  incision  is  made  by  cutting  upwards. 
A  probe  is  then  introduced  into  the  bladder,  and,  the 
staff  being  removed,  the  finger  is  passed  into  that  viscus 
by  steady  dilatation  of  the  parts,  with  some  laceration 
of  the  prostate.  The  object  in  this  operation  is  to  enter 
the  bladder  with  the  least  amount  of  cutting,  and  by 
dilatation  rather  than  incision. 

Parts  divided. — (1)  Skin  and  superficial  fascia; 
(2)  sphincter  ani ;  (3)  central  point  of  perineum  ;  (4) 
lower  border  of  triangular  ligament ;  (5)  whole  length 
of  membranous  urethra  ;  (6)  compressor  urethrse. 

Advantages. — (1)  The  bleeding  is  much  less  than 
in  the  lateral  operation,  the  slight  vascularity  of  the 
raphe  being  well  known.  (2)  The  pelvic  fascia  is  much 
less  likely  to  lie  wounded  if  the  bladder  be  entered  by 


39°  Surgical  Applied  Anatomy.  [Chap.  xvm. 

dilation  rather  than  by  incision,  as  in  the  lateral 
procedure. 

Disadvantages. — (1)  The  bulb  is  in  great  risk  of 
being  wounded.  It  must,  however,  be  noted  that 
wounds  of  the  bulb  in  the  middle  line  do  not  bleed 
readily,  as  a  rule.  (2)  The  amount  of  space  obtained 
for  the  removal  of  the  stone  is  very  slight.  (3)  In 
children  the  operation  in  its  integrity  is  scarcely  possible, 
since  the  prostate  is  quite  rudimentary,  and  the  slight 
attachments  of  the  parts  are  such  that,  in  using  forcible 
dilatation,  the  bladder  may  readily  be  torn  from  the 
urethra.  If  the  incision  be  made  upwards,  and  one 
finger  be  retained  in  the  rectum,  the  risk  of  wounding 
the  gut  is  not  great. 

In  lithotomy,  and  in  other  operations  for  reaching 
the  neck  of  the  bladder  through  the  perineum,  it  should 
be  remembered  that  the  bladder  lies  at  a  depth  of  from 
2^  to  3  inches  from  the  surface  when  the  body  is  in 
lithotomy  position.     (Fig.  52.) 

Suprapubic  lithotomy. — This  operation  has 
been  revived  of  late  years,  and  in  cases  in  which  litho- 
lapaxy  is  contraindicated  has  practically  supplanted 
the  two  forms  of  lithotomy  just  described.  In  order 
to  bring  the  summit  of  the  bladder  well  above  the  sym- 
physis, both  bladder  and  rectum  may  be  dilated.  Into 
the  former  viscus,  tepid  water  or  boracic  lotion  is 
injected.  It  is  found  that  in  the  adult  8  to  10  ounces  is 
sufficient  to  ensure  the  desired  distension.  The  rectum 
is  dilated  by  some  operators  by  means  of  a  soft  rubber 
bag.  The  gut,  when  thus  distended,  pushes  forward 
the  bladder,  and  gives  it  a  firm  basis  upon  which  to 
rest.  In  the  adult  from  10  to  14  ounces  are  usually 
introduced  into  the  bag.  Distension  of  the  rectum 
alone  will  elevate  the  bladder,  but  it  will  usually  have 
no  effect  upon  the  reflection  of  peritoneum.  In  operating 
upon  children  the  rectal  bag  is  very  seldom  required, 
and  many  surgeons  do  not  employ  it  in  any  case.  In 
the  case  of  a  male  child,  aged  five,  the  injection  of  3 
ounces  of  water  into  the  bladder  caused  the  reflection 
of    peritoneum  to  mount  to  more  than  1  inch   above 


chap,  xvi n.]  The  Pelvis  and  Perineum.  391 

the  symphysis.  An  incision,  some  3  inches  in  length,  is 
made  immediately  above  the  symphysis  in  the  median 
line.  The  bladder  is  exposed  below  the  peritoneum, 
is  drawn  forwards  by  a  hook,  and  opened. 

The     Madder. — When     empty     the     bladder     is 
flattened  and   of  triangular   outline,   and  lies  against 
the  anterior  wall   of  the   pelvis.     The   empty   bladder 
may  be  found  in  one  of  two  conditions  (as  demonstrated 
by   Dr.   Hart  in  the  adult  female   bladder).     It   may 
be  small,  oval,  and  firm,  with  its  upper  wall  convex 
towards    the    abdomen.     In    vertical    antero-posterior 
section  the  urethra  forms  with  the  cavity  of  the  bladder 
a   curved   slit   (the   systolic   empty   bladder).     It   may 
be  larger,  and  soft,  with  its  upper  surface  concave  to- 
wards  the   abdomen,   and   fitting   into   the   concavity 
of  the  lower  wall  or  surface.     In  the  section  named, 
the  urethra  forms,  with  the  bladder  cavity,  a  Y-shaped 
figure,  the  two  diverging  limbs  of  the  Y  corresponding 
to  the  concavity  named  (the  diastolic  empty  bladder). 
When  moderately  distended  it  is  of  rounded  outline  ; 
when  completely  distended  it  assumes  an  oval  outline, 
and  rises  out  of  the  pelvis.     As  distension  of  the  bladder 
increases,  the  summit  of  the  viscus  is  brought  more 
and  more  in  contact  with  the  anterior  abdominal  wall, 
the  organ  becoming  also  more  convex  on  its  posterior 
than  on  its  anterior  surface.     This  tendency  for  the 
summit  of  the  distended  bladder  to  press  itself  against 
the  anterior  parietes  is  of  good  service  in  tapping  the 
organ  above  the  pubes,  and  in  suprapubic  lithotomy. 
When  greatly  distended  it  may  reach  the  umbilicus, 
and  may  even  touch  the  diaphragm.     The  usual  capacity 
of  the  organ  is  about  one  pint,  out  when  fully  occupied 
it   may   hold   some   quarts.     When   both   bladder  and 
rectum  are  quite  empty  the  apex  of  the  bladder  and 
the  pre-vesical  reflection  of  the  peritoneum  are  a  little 
below  the  upper  margin  of  the  symphysis  pubis.     As 
the  distended  bladder  ascends  above  the  pubes  it  dissects 
the  serous  membrane  from  the  parietes,  and  the  layer 
so  lifted  off  forms  a  cul-de-sac  or  fold  of  peritoneum 
between  the  upper  part  of  the  anterior  surface  of  the 


392 


Surgical  Applied  Anatomy.  [Chap,  xvm 


Pig.  52.  —A  Vertical  Anteroposterior  Section  of  the  Male  Pelvis 
(Braune). 

bladder  and  the  parietes.  When  the  apex  of  the  bladder 
is  2  inches  above  the  pubes  the  peritoneal  reflection 
is  probably  not  more  than  £  of  an  inch  above  the  same 


Chap,  xvm.]  The  Pelvis  and  Perineum.  393 

point  of  bone.  When  the  apex  of  the  bladder  is  midway 
between  the  umbilicus  and  the  pubes  there  may  be 
2  inches  (vertical)  of  the  anterior  abdominal  wall  in 
the  middle  line  and  immediately  above  the  symphysis 
devoid  of  peritoneal  lining.  Thus  it  happens  that  the 
distended  viscus  may  be  readily  tapped  above  the  pubes 
without  the  peritoneum  being  wTounded.  As  the  bladder 
becomes  distended,  not  only  does  it  rise  into  the  abdomen, 
but  it  extends  also  towards  the  perineum,  diminishing 
the  length  of  the  prostatic  and  membranous  urethra. 
In  suprapubic  lithotomy  that  tendency  to  extend  down- 
wards is  prevented  by  the  rectal  bag  (page  390). 

Between  the  anterior  surface  of  the  bladder  and  the 
symphysis,  and  shut  in  by  the  peritoneum  above,  is  a 
loose  layer  of  connective  tissue.  The  looseness  of  this 
connective  tissue  permits  the  bladder  to  readily  alter 
its  dimensions  without  disturbing  the  connections 
of  the  organ.  In  injuries  to  the  pelvis  and  to  the  front 
of  the  bladder  a  diffuse  inflammation  may  be  set  up 
in  this  tissue  and  assume  serious  proportions.  I  have 
reported  a  case  wrhere  an  extensive  suppuration  in  this 
area  followed  upon  aspiration  of  the  bladder  above 
the  pubes,  and  led  to  death.  Like  suppuration  has 
followed  suprapubic  lithotomy.  In  rupture  of  the 
anterior  wrall  of  the  viscus  the  urine  escapes  into  this 
district  of  cellular  tissue  ;  a  limited  suppuration  may 
follow  and  recovery  ensue. 

The  bladder,  although  fairly  fixed,  has  been  found 
in  inguinal,  femoral,  and  vaginal  hernias.  In  the  erect 
position  its  neck  (in  the  male)  lies  on  a  horizontal  line 
drawn  from  before  backwards  through  a  point  a  little 
below  the  middle  of  the  symphysis,  and  is  placed  about 
\\  inches  (3  cm.)  behind  that  articulation  (Tillaux). 

Relations  to  the  peritoneum. — The  anterior  surface 
is  entirely  devoid  of  peritoneum,  while  the  superior 
surface  is  entirely  covered  by  that  membrane.  At  the 
sides  there  is  no  peritoneum  in  front  of,  or  below,  the 
obliterated  hypogastric  arteries.  On  the  posterior 
aspect  of  the  bladder  the  serous  membrane  extends 
down  as  far  as  a  transverse  line,  uniting  the  upper 


394  Surgical  Applied  Anatomy.  [Chap;  XWti. 

parts  of  the  two  seminal  vesicles,  so  that  the  upper 
ends  of  the  vesicles,  as  well  as  the  ureters,  where  they 
enter  the  bladder,  are  covered  by  peritoneum.  This 
recto-vesical  pouch  of  peritoneum  in  the  adult  extends 
to  within  about  3  inches  of  the  anus,  and  does  not  reach 
below  a  line  1  inch  above  the  base  of  the  prostate. 
Harrison  Cripps  gives  the  distance  of  the  pouch  from 
the  anus  as  2|  inches  when  the  bladder  and  rectum 
are  both  empty,  and  as  2>\  inches  when  those  viscera 
are  distended.     (See  Bladder  in  the  Child,  page  398.) 

Puncture  of  the  bladder  per  rectum. — 
The  base  of  the  bladder  is  adherent  to  the  rectum  by 
dense  areolar  tissue  over  a  triangular  area,  the  apex 
of  which  is  formed  by  the  prostate,  the  sides  by  the 
diverging  seminal  vesicles,  and  the  base  by  the  recto- 
vesical fold  of  peritoneum.  This  triangle  is  equilateral, 
and  in  the  dissected  specimen  measures  about  1^  inches 
on  all  sides.  It  corresponds  to  the  trigone  on  the  inner 
surface  of  the  viscus.  It  is  through  this  triangle,  and 
as  near  as  possible  to  the  prostate,  that  the  bladder 
is  tapped  when  the  operation  is  performed  per  rectum. 
The  recto-vesical  fold  of  peritoneum  is  raised,  and  is 
carried  still  farther  from  the  anus  when  the  organ  is 
distended. 

liupture  of  bladder. — The  bladder  may  be 
ruptured  by  violence  applied  to  the  anterior  abdominal 
wall  apart  from  pelvic  fracture  or  external  evidence 
of  injury.  Such  a  rupture  can,  however,  hardly  happen 
to  the  empty  bladder,  which  should  be  full  or  distended 
at  the  time.  It  is  very  rare  for  the  rupture  to  be  on 
the  anterior  surface  only.  As  a  rule,  the  tear  involves 
the  superior  or  abdominal  surface,  and  implicates  the 
peritoneum.  The  injury,  therefore,  is  very  fatal  (five 
recoveries  out  of  seventy-eight  cases).  In  some  cases 
of  vesical  rupture  the  surgeon  has  opened  the  abdomen 
and  has  stitched  up  the  rent  in  the  viscus  with  perfect 
success.  The  bladder  may  be  torn  by  fragments  of 
bone  in  fractures  of  the  pelvis,  or  by  violence  applied 
through  the  rectum  or  vagina.  A  case,  for  example, 
is  reported  (Holmes'  "  System  of  Surgery ")  of  a  man 


Chap,  xviii.]  The  Pelvis  and  Perineum.  395 

who  fell  upon  a  pointed  stake  fixed  in  the  earth.  The 
stake  passed  through  the  anus,  pierced  the  rectum, 
and  entered  the  bladder  near  the  prostate.  The  patient 
recovered,  the  wound  having  been  made  in  the  tri- 
angular area  on  the  fundus  of  the  bladder  alluded  to 
above,  and  therefore  outside  the  peritoneum.  The 
viscus  may  be  ruptured  by  an  accumulation  of  urine, 
as  seen  in  cases  of  congenital  closure  of  the  urethra 
in  some  infants.  In  the  museum  of  the  Royal  College 
of  Surgeons  is  a  preparation  of  "  the  bladder  of  a  woman 
which  burst  near  the  entrance  of  the  ureter  in  con- 
sequence of  neglected  retention  of  urine."  In  neglected 
cases  of  stricture  in  the  male  the  urethra  gives  way 
rather  than  the  bladder,  and  an  extravasation  of  urine 
into  the  perineum  follows.  A  small  puncture  of  the 
bladder,  as,  for  example,  that  made  by  a  fine  trochar, 
is  at  once  closed  by  the  muscular  contraction  of  its  wall. 
The  mucous  membrane  of  the  bladder  is  very 
lax,  to  allow  of  its  accommodating  itself  to  the  varying 
changes  in  the  size  of  the  viscus.  Over  the  trigone, 
however,  it  is  closely  adherent,  and  were  it  not  so  the 
loose  mucous  membrane  would  be  constantly  so  pro- 
lapsed into  the  urethral  orifice  during  micturition  as 
to  block  up  the  neck  of  the  bladder.  The  trigone  is 
bounded  by  three  orifices,  for  the  urethra  and  the  two 
ureters,  and  forms  an  equilateral  triangle,  measuring 
about  lh  inches  on  all  sides.  It  is  here  that  the  effects 
of  cystitis  are  most  evident,  and  the  unyielding  character 
of  the  mucous  membrane  over  the  trigone  serves  in 
part  to  explain  the  severe  symptoms  that  follow  acute 
inflammation  of  that  structure.  Since  the  orifice  of 
the  urethra  forms  the  lowest  part  of  the  bladder  in  the 
erect  posture,  it  follows  that  calculi  gravitate  towards 
the  trigone,  and  are  very  apt  to  irritate  that  part  of 
the  interior.  The  same  remark  applies  to  foreign  bodies 
in  the  viscus.  The  mucous  membrane  about  the  trigone 
and  neck  is  very  sensitive,  whereas  the  interior  of 
the  remainder  of  the  bladder  appears  to  be  singularly 
defective  in  common  sensation.  This  can  be  well  noted 
in  using  sounds  and  catheters. 


396  Surgical  Applied  Anatomy.  [Chap.  xvm. 

The  sensory  nerves  for  the  bladder  are  derived 
mainly  from  the  third  sacral  segment,  to  a  less  degree 
from  the  second  and  fourth,  and  pass  to  the  bladder  from 
the  third  and  sometimes  fourth  sacral  nerve  through  the 
nervi  errigentes.  The  skin  of  the  scrotum,  penis,  and 
mucous  membrane  of  the  urethra  are  supplied  from 
the  same  segments.  Hence,  in  diseases  of  the  bladder, 
especially  of  the  trigone,  pain  is  referred  along  the  dis- 
tribution of  the  perineal  nerves.  The  motor  nerves  of 
the  bladder  come  from  the  eleventh  and  twelfth  dorsal 
and  first  lumbar  segments,  and  pass  to  the  bladder  by  the 
hypogastric  and  pelvic  plexuses.  Both  the  sensory 
and  motor  centres  are  concerned  in  the  reflex  act 
of  micturition.  Being  situated  at  different  levels 
of  the  cord  one  centre  may  be  affected  without  the 
other. 

In  the  muscular  coat  of  the  bladder  the  fibres 
are  collected  into  bundles  which  interlace  in  all  direc- 
tions. When  the  viscue  becomes  hypertrophied 
these  bundles  are  rendered  very  distinct,  and  produce 
the  appearance  known  as  "  fasciculated  bladder." 
This  simply  means  that  the  muscle  of  the  bladder, 
having  been  unduly  exercised  to  overcome  some  obstruc- 
tion to  the  escape  of  urine,  increases  in  size,  as  do  other 
much  exercised  muscles,  and  that  increase  serves  to 
demonstrate  the  arrangement  of  the  individual  bundles. 
In  a  fasciculated  bladder  the  muscular  bundles  present 
much  the  appearance  of  some  of  the  columnae  earner 
in  the  heart.  It  will  be  understood  that  the  bladder 
wall  between  the  muscular  bundles  is  comparatively 
thin,  and  may  yield  when  the  viscus  is  distended.  By 
such  distension  the  mucous  membrane  becomes  bulged 
out  between  the  unyielding  muscle  bundles,  so  that 
sacculi  are  formed,  and  the  appearance  known  as 
"  sacculated  bladder "  is  produced.  In  these  sacculi 
urine  may  lodge  and  decompose,  phosphatic  deposits  may 
collect,  and  calculi  may  develop  (encysted  calculi).  In 
some  cases  the  parietes  yield,  especially  at  one  part, 
and  one  large  saccule  is  produced.  In  this  way  a  sacculus 
may  be  formed  which  in  time  may  become  almost  as  large 


chap,  xviii.]  The  Pelvis  and  Perixeum.  397 

as  tlio  bladder  itself,  and  give  rise  to  the    erroneous 

description  of  "  double  bladder,-'  etc. 

The  anterior  wall  of  the  bladder  is  thicker  and 
stronger  than  the  posterior,  and  in  cases  of  hypertrophy 
the  increase  appears  to  mainly  involve  the  anterior 
wall.  The  difference  between  the  two  parts  is  well 
shown  in  frozen  sections  (Symington). 

The  ureters  run  for  f  of  an  inch  in  the  muscular 
wall  of  the  viscus,  and  their  oblique  course,  together 
with  the  action  of  the  muscular  tissue  about  them, 
tends  to  prevent  regurgitation  of  urine.  In  cases  of 
retention  the  ureters  become  distended  ;  but  this  is  due 
rather  to  accumulation  of  urine  within  them  than  to 
its  reflux  from  the  bladder. 

In  cases  of  great  distension  of  the  bladder  the  neck 
of  the  viscus  is  opened  up  by  the  pressure  from  within, 
and  the  patient  exhibits  the  feature  of  overflow  of  urine. 

The  female  bladder  is  less  capacious  than  that 
of  the  male.  Its  neck  is  situate  a  trifle  nearer  to  the 
symphysis  than  it  is  in  the  male,  and  lies  in  a  hori- 
zontal line  continued  back  from  the  lower  border  of  the 
symphysis.  There  being  no  prostate,  the  neck  of  the 
bladder  is  very  distensible,  and  this  fact,  taken  in  con- 
nection with  the  shortness  and  dilatability  of  the  urethra, 
allows  of  most  stones  being  extracted  by  forceps  without 
cutting.  By  simple  dilatation,  stones  of  a  diameter  of 
I  of  an  inch  have  been  removed.  Through  the  dilated 
urethra  the  orifices  of  the  ureters  can  be  seen  and  ex- 
amined. The  intimate  relation  of  the  bladder  to  the 
vagina  allows  it  to  be  examined  well  from  the  latter 
passage,  and  the  comparative  thinness  of  the  dividing 
wall  serves  to  explain  the  frequency  of  vesico-vaginal 
fistula?.  Strange  foreign  bodies  have  been  introduced 
into  the  female  bladder,  such  as  hair-pins,  crochet  hooks, 
sealing-wax,  penholders,  and  the  like. 

The  orifice  of  the  ureter  is  3  cm.  from  the  cervix 
uteri,  and  4  cm.  from  the  vesical  opening  of  the  urethra. 
Its  close  relation  to  the  cervix  renders  it  liable  to  injury 
in  supravaginal  amputation  of  that  part,  and  in  certain 
operations  on  the  uterus. 


398  Surgical  Applied  Anatomy;  [Chap.  xvm. 

The  bladder  in  the  child  is  egg-shaped,  and 
its  vertical  axis  is  relatively  much  greater  than  it  is 
in  the  adult.  The  larger  end  of  the  egg-shaped  cavity 
is  directed  downwards  and  backwards.  It  can  hardly 
be  said  that  there  is  any  base  or  fundus  to  the  child's 
bladder.  The  viscus  is  situated  mainly  in  the  abdomen, 
the  pelvis  being  small  and  very  shallow.  At  birth  the 
orifice  of  the  urethra  is  on  a  level  with  the  upper  edge 
of  the  symphysis.  Although  the  bladder  projects  so 
freely  into  the  abdomen,  its  anterior  wall  is  still  entirely 
uncovered  by  peritoneum.  On  the  posterior  wall  the 
serous  membrane  extends  lower  down  than  in  the  adult, 
reaching  the  level  of  the  urethral  orifice  at  the  time  of 
birth,  and  the  level  of  the  prostate  in  young  male  children. 
The  prostate  is  exceedingly  small  in  children.  Thompson 
states  that  at  the  age  of  seven  years  it  only  weighs  thirty 
grains,  whereas  in  subjects  between  eighteen  and  twenty 
it  weighs  two  hundred  and  fifty  grains.  The  bladder 
wall  in  the  child  is  so  thin  that  in  sounding  for  stone 
it  is  said  that  a  "  click "  may  be  elicited  by  striking 
the  pelvis  through  the  parietes  of  the  viscus. 

The  prostate. — The  prostate  is  situated  about 
£  of  an  inch  below  the  symphysis  pubis,  and  rests  upon 
the  rectum  in  front  of  the  bend  between  the  second  and 
third  segments  of  that  viscus.  It  is,  therefore,  placed 
within  l£  to  2  inches  from  the  anus,  and  can  be  readily 
examined  from  the  bowel. 

The  secretion  from  the  gland  is  discharged  through 
a  number  of  long  and  very  narrow  ducts.  In  certain 
forms  of  prostatic  irritation,  little  white  opaque  threads, 
very  much  like  short  pieces  of  cotton,  are  found  in  the 
urine,  and  are  actual  casts  of  the  prostatic  ducts. 

The  prostate  is  enveloped  in  a  firm  capsule  derived 
from  the  pelvic  fascia,  and  it  is  to  this  fascia  that  we  look 
for  an  explanation  of  the  course  of  prostatic  abscess. 

The  prostatic  abscess  usually  bursts  into  the 
urethra,  that  being  the  direction  in  which  least  resistance 
is  encountered.  If  it  does  not  enter  the  urethra,  it  will 
probably  open  into  the  rectum,  there  being  only  one 
layer  of  thejpelvic  fascia,  and  that  layer  not  a  thick  one, 


chap,  xviii.]  The  Pelvis  and  Perineum.  399 

between  the  two  organs.  Indeed,  the  posterior  part  of  the 
prostatic  capsule,  and  the  anterior  part  of  the  sheath 
of  the  rectum,  are  continuous.  Failing  these  two  points 
of  exit,  the  abscess  may  progress  towards  the  perineum. 
This  course,  however,  is  not  very  usual,  the  advance 
of  the  abscess  being  resisted  by  the  dense  posterior 
layer  of  the  triangular  ligament,  with  the  lower  edge  of 
which  the  prostatic  capsule  is  continuous.  If  the  abscess 
reaches  the  perineum,  it  will  do  so  by  running  along 
the  side  of  the  rectum.  The  abscess  cannot  make  its 
way  into  the  pelvic  cavity,  its  movement  in  that  direction 
being  resisted  by  the  pubo-prostatic  ligaments  which 
form  one  of  the  very  densest  portions  of  the  pelvic  fascia. 
This  encasement  of  the  gland  in  an  unyielding  membrane 
will  serve  to  in  part  explain  the  severe  pain  felt  in  acute 
prostatic  abscess.  In  acute  prostatitis  pains  are  referred 
over  the  tip  of  the  last  rib  (tenth  dorsal  nerve),  over  the 
posterior  iliac  spine  (eleventh  dorsal  nerve),  or  even  to  the 
soles  of  the  feet  (third  sacral  nerve).  It  derives  its  nerve 
supply  from  the  lower  three  dorsal  and  upper  three 
sacral  segments  ;  hence  the  widely  distributed  character 
of  the  referred  pains  (Head). 

Hypertrophy  of  tlie  prostate. — The  average 
measurements  of  the  normal  prostate  are  \\  inches 
across  at  its  widest  part,  and  1  \  inches  from  before  back- 
wards, or  from  apex  to  base.  After  the  age  of  fifty-three 
the  organ  is  very  apt  to  become  hypertrophied  ;  and, 
according  to  Sir  Henry  Thompson,  this  hypertrophy 
may  be  considered  to  exist  when  the  gland  measures 
2  inches  from  side  to  side,  or  wrhen  it  weighs  1  ounce. 
The  usual  weight  of  the  prostate  is  6  drachms.  If  the 
enlargement  mainly  affect  the  lateral  lobes,  it  will  be 
understood  that  the  hypertrophy  may  attain  consider- 
able dimensions  without  retention  of  urine  being  pro- 
duced. On  the  other  hand,  a  comparatively  trifling 
enlargement  of  the  middle  lobe  may  almost  entirely 
block  the  orifice  of  the  urethra.  If  the  affection  be 
general,  the  prostatic  urethra  is  lengthened,  and  if  one 
lateral  lobe  be  more  enlarged  than  the  other,  the  canal 
deviates  to  one  side.     When  the  enlargement  particularly 


4-oo  Surgical  Applied  Anatomy.  [Chap,  xviii. 

affects  the  middle  lobe,  the  prostatic  urethra,  which  is 
normally  almost  straight,  becomes  considerably  curved, 
the  curve  being  sometimes  very  abrupt. 

It  is  important  to  note  that  enlargement  of  the  middle 
lobe  alone  can  hardly  be  made  out  by  rectal  examination. 

The  severity  of  the  symptoms  in  a  case  of  hyper- 
trophy of  the  prostate  bears  little  or  no  relation  to  the 
apparent  size  of  the  gland  as  felt  per  rectum.  A  portion 
of  the  enlarged  body  may  project  into  the  bladder. 
This  usually  takes  the  form  of  a  projecting  middle  lobe 
which,  when  viewed  from  the  interior  of  the  bladder, 
may  appear  as  a  distinct  well-rounded  pedunculated 
or  sessile  growth. 

In  the  operation  of  prostatectomy  this  projecting 
and  most  troublesome  mass  is  removed  through  a  supra- 
pubic incision.  The  prostate  is  a  sexual  organ,  and 
its  size  and  development  depend  on  the  presence  and 
activity  of  the  testes.  Castration  prevents  its  develop- 
ment or  causes  atrophy  if  already  developed.  Removal 
of  one  testicle  causes  a  partial  atrophy,  and  section  of 
the  vasa  differentia  has  usually  a  similar  effect.  These 
two  facts  show  that  the  atrophy  is  not  due  to  the  removal 
of  any  internal  secretion  which  the  testicle  may  impart 
to  the  blood.  The  effect  is  probably  produced  through 
the  nervous  system.  The  prostate  and  testicle  derive 
their  nerves  mainly  from  the  tenth  dorsal  spinal  segment. 
Between  the  prostate  and  its  capsule  is  an  extensive 
plexus  of  veins,  the  prostatic  plexus,  into  which  enters 
the  dorsal  vein  of  the  penis.  This  plexus  is  cut  in  lateral 
lithotomy,  and  it  is  through  its  vessels  that  septic  matter 
is  probably  absorbed  in  cases  of  pyaemia  following  that 
operation.  Its  lymphatics,  which  are  numerous,  pass 
to  a  group  of  glands  on  the  wall  of  the  pelvis,  between 
the  external  and  internal  iliac  arteries. 

The  male  urethra,  is  about  8£  inches  in  length 
(21  cm.),lj  inches  being  devoted  to  the  prostatic  urethra, 
|  of  an  inch  to  the  membranous,  and  6^  inches  to  the 
penile  or  spongy  portion.  Between  the  ages  of  four 
and  six  years  its  length  is  8  to  9  cm.,  and  between  ten 
and  thirteen  years  10  to  11  cm.     The  canal  may  be 


Chap. xviii.]  The  Pelvis  and  Perineum.  401 

divided  into  a  fixed  and  a  movable  part.  The  fixed  part 
extends  from  the  neck  of  the  bladder  to  the  posterior 
extremity  of  the  penile  urethra  at  the  point  of  attachment 
of  the  suspensory  ligament.  The  fixed  part  describes 
an  even  curve,  fairly  represented  by  the  line  of  a  "  short 
curve "  metal  catheter.  The  two  ends  of  the  curve 
lie  about  in  the  same  line,  viz.  one  drawn  across  the 
lower  end  of  the  symphysis,  and  at  right  angles  to  the 
vertical  axis  of  that  articulation.  The  curve  is  formed 
around  this  line,  its  summit  corresponding  to  a  pro- 
longation of  the  vertical  axis  of  the  symphysis,  and  to 
about  the  centre  of  the  membranous  urethra.  This 
part  of  the  tube  lies  about  1  inch  below  the  pubic  arch. 
The  movable  portion  of  the  urethra  forms,  when  the 
penis  is  dependent,  a  second  curve  in  the  opposite  direc- 
tion, so  that  the  whole  canal  follows  somewhat  the 
outline  of  the  letter  S. 

The  prostatic  portion  of  the  urethra  will  be  nearly 
vertical.  It  is  surrounded  by  circular  muscular  fibres 
which  may  give  rise  to  a  spasmodic  stricture.  This 
part  of  the  canal  corresponds  to  the  posterior  ventral 
part  of  the  urogenital  sinus  of  the  cloaca,  which  receives 
the  Wolffian  and  Miillerian  ducts.  The  sinus  pocularis 
or  uterus  masculinus,  in  the  floor  of  this  part  of  the 
urethra,  represents  the  united  ends  of  the  rudimentary 
Miillerian  ducts. 

That  part  of  the  urethral  canal  which  lies  beyond 
the  prostate  is  of  different  origin,  and  is  a  portion  of 
the  anterior  segment  of  the  cloaca,  which  has  been 
formed  into  a  canal  by  a  superficial  union  of  the  tegu- 
mentary  folds  in  the  median  line. 

The  penile  or  spongy  portion  of  the  urethra  is  sur- 
rounded by  the  erectile  tissue  of  the  corpus  spongiosum 
urethra?,  which  is  thickest  on  the  under  side  of  the 
canal.  A  very  thin  layer  of  erectile  tissue  surrounds 
the  membranous  urethra  lying  beneath  the  fibres  of 
the  compressor  urethras. 

In  introducing  a  catheter  it  must  be  noted  that  while 
the  instrument  passes  along  the  movable  urethra,  the 
canal  accommodates  itself  to  the  catheter,   but  while 


402  Surgical  Applied  Anatomy.  [Chap.  xvm. 

traversing  the  fixed  segment  the  instrument  must 
accommodate  itself  to  the  unyielding  canal.  In  intro- 
ducing a  catheter  in  the  recumbent  posture  the  penis 
is  held  vertically  upwards,  and  in  this  way  the  curve 
formed  by  the  movable  urethra  is  obliterated.  The 
instrument  is  best  kept  close  to  the  surface  of  the  groin, 
and  over  and  parallel  to  Poupart's  ligament.  When 
the  fixed  urethra  is  reached,  the  handle  of  the  catheter 
is  brought  to  the  middle  line,  and  then,  being  kept 
strictly  in  the  median  plane  of  the  body,  is  depressed 
between  the  legs,  so  that  the  front  of  the  instrument 
may  follow  the  natural  curve  of  the  canal.  The  greatest 
difficulty  in  the  introduction  is  generally  experienced 
at  the  point  where  the  movable  and  fixed  parts  of  the 
urethra  meet ;  or,  rather,  in  practice,  at  a  spot  a  little 
behind  this  point,  viz.  at  the  anterior  layer  of  the  tri- 
angular ligament.  At  this  spot  the  tube  abruptly* 
becomes  not  only  very  fixed,  but  also  very  narrow, 
and  a  part  of  it  is  reached  where  muscular  tissue  is 
very  abundant,  and  where  resistance  from  muscular 
spasm  is  therefore  likely  to  be  most  marked. 

It  thus  happens  that  when  a  false  passage  has  been 
made  by  a  catheter  in  a  case  where  no  stricture  exists 
to  offer  a  definite  obstruction,  the  instrument  is  usually 
found  to  have  left  the  canal  just  in  front  of  the  triangular 
ligament. 

Some  other  points  in  connection  with  catheterism 
will  be  noted  subsequently. 

The  urethral  canal  must  not  be  regarded  as 
forming  an  open  tube  like  a  gas-pipe.  Except  when 
urine  or  an  instrument  is  passing  along  it,  the  tube 
appears  on  section  as  a  transverse  slit,  the  superior 
and  inferior  walls  being  in  contact.  This  fact  should 
be  remembered  in  amputation  of  the  penis  by  the 
ecraseur.  In  the  fossa  navicularis  the  tube  appears 
as  a  vertical  slit. 

The  prostatic  part  of  the  canal  is  the  widest  and 
most  dilatable  portion  of  the  whole  urethra.  It  is 
widest  at  its  centre,  having  here  a  diameter  of  nearly 
£  an  inch  ;    at  the  bladder  end  its  diameter  is  about 


Chap;  XVIII.]   Tf/E   PELVIS   AND    PERINEUM.  403 

\  of  an  inch,  while  at  the  anterior  extremity  of  this 
part  of  the  urethra  the  measurement  is  a  little  less 
than  \  of  an  inch.  When  small  catheters  are  being 
introduced  their  points  may  lodge  in  the  orifice  of  the 
utricle,  unless  the  tip  of  the  instrument  le  kept  well 
along  the  roof  of  the  canal.  The  ejaculatory  ducts 
open  into  the  prostatic  urethra,  and  thus  it  happens 
that  inflammation  of  this  part  of  the  canal  may  spread 
back  along  those  ducts  to  the  seminal  vesicles,  and 
from  thence  along  the  vas  deferens  to  the  epididymis. 
It  is  by  spreading  along  these  parts  that  inflammation 
of  the  testicle  is  set  up  in  gonorrhoea,  involving  the 
prostatic  urethra,  and  it  will  be  understood  that  a  like 
inflammation  may  follow  lateral  lithotomy,  impacted 
stone  in  the  prostatic  urethra,  prostatic  abscess,  and 
the  like.     Stricture  never  occurs  in  this  part. 

The  membranous  urethra  is,  with  the  exception 
of  the  meatus,  the  narrowest  part  of  the  entire  tube. 
Its  diameter  is  about  ^  of  an  inch.  It  is  fixed  between 
the  two  layers  of  the  triangular  ligament,  and  is  the 
most  muscular  part  of  the  canal.  It  is  at  this  spot, 
therefore,  that  what  is  known  as  "  spasmodic  stricture  " 
usually  occurs.  In  any  case,  the  contraction  of  the 
compressor  urethrse  often  offers  an  appreciable  amount 
of  resistance  to  the  passage  of  a  catheter  or  sound. 

The  penile  urethra  is  dilated  at  either  end  ;  viz. 
at  the  parts  occupying  the  bulb  and  the  glans  penis 
respectively.  The  diameter  of  the  bulbous  urethra  is 
midway  between  that  of  the  prostatic  and  membiunous 
segments  of  the  canal,  while  that  of  the  greater  part 
of  the  penile  urethra  is  midway  between  that  of  the 
bulbous  and  membranous  portions.  It  is  in  the  bulbous 
urethra  that  organic  stricture  is  the  most  commonly 
met  with.  The  meatus  measures  from  I  to  \  of  an  inch, 
and  therefore  if  a  catheter  will  pass  the  meatus  it  will 
pass  along  any  part  of  the  canal  if  normal.  Its  aperture 
is  very  resisting,  and  has  often  to  be  incised  to  allow 
the  larger  instruments  to  pass. 

The  narrowest  parts  of  the  urethra,  therefore,  are 
at  (1)  the  meatus,  and  (2)  in  the  membranous  segment, 


404  Surgical  Applied  Anatomy.  tchaP.  xvin. 

especially  at  its  anterior  end.  It  is  at  these  points 
that  calculi  passed  from  the  bladder  are  most  apt  to 
lodge.  The  widest  portions  of  the  canal,  on  the  other 
hand,  are  at  (1)  the  fossa  navicularis,  (2)  the  bulbous 
part  of  the  urethra,  and  (3)  the  centre  of  the  prostatic 
portion. 

Keegan  has  shown  that  the  urethra  of  a  male  child 
two  or  three  years  of  age  will  take  a  No.  9  catheter. 
In  boys  between  eight  and  ten  years  a  No.  11  lithotrite 
may  be  passed. 

It  will  be  obvious,  therefore,  that  the  operation  of 
lithotrity  may  be  performed  upon  quite  young  male 
children,  and  that  fragments  of  crushed  calculus  of  no 
small  dimensions  may  be  removed  from  the  bladders 
of  such  patients  by  washing. 

The  mucous  membrane  presents,  in  addition 
to  many  mucous  glands,  several  lacunas,  the  orifices  of 
which  for  the  most  part  open  towards  the  meatus. 
These  lacunas  are  most  numerous  in  the  bulbous  urethra, 
and  occupy  the  floor  rather  than  the  roof  of  the  canal. 
In  passing  small  catheters,  therefore,  the  point  of  the 
instrument  should  be  kept  along  the  upper  surface 
of  the  tube,  so  that  it  may  not  become  engaged  in  any 
of  these  spaces.  The  largest  lacuna,  the  lacuna  magna, 
is  situate  in  the  roof  .of  the  fossa  navicularis,  and  may 
readily  engage  the  point  of  a  small  instrument. 

Otis  has  endeavoured  to  show  that  a  definite  relation 
exists  between  the  circumference  of  the  penis  and  the 
circumference  of  the  urethra,  a  relation  represented 
by  the  proportions  2 '25  :  1,  and  makes  use  of  instru- 
ments of  large  size,  which,  when  passed,  seem  to 
demonstrate  rather  the  dilatability  of  the  canal  than 
any  certain  anatomical  relationship. 

The  urethra  may  be  ruptured  by  the  patient 
falling  astride  of  some  hard  substance.  In  such  an 
injury  it  is  crushed  between  the  hard  substance  and 
the  pubic  arch.  The  part  of  the  canal,  therefore,  that 
is  most  often  damaged  is  the  membranous  segment, 
and  the  posterior  part  of  the  penile  division.  The  more 
the  body  is  bent  forwards  at  the  time  the  perineum  is 


Chap,  xviii.]      The  Pelvis  and  Perineum.         405 

Struck,  the  greater  is  the  length  of  penile  urethra  that 
may  be  crushed  against  the  pubes. 

The  female  urethra  is  about  1^  inches  in  length, 
and  has  a  diameter  of  from  \  to  \  of  an  inch.  It  is 
capable,  however,  of  great  distension.  In  the  erect 
position  the  canal  is  nearly  vertical,  and  in  the  recum- 
bent posture  almost  horizontal. 

Penis. — The  skin  covering  the  bulk  of  the  organ 
is  thin  and  fine,  and  the  subcutaneous  tissue  is  scanty 
and  lax.     It  follows,  from  the  looseness  of  this  tissue, 
that  the  skin  is  very  ^distensible  and  movable.       The 
latter  fact  should  be  borne  in  mind  in    circumcision, 
for  in  performing  that  operation  the  skin  of  the  penis 
can  be  so  readily  drawn  forwards  over  and  beyond  the 
glans,  that  if  it  is  excised  as  far  back  as  possible  the 
greater  part  of  the  organ  may  be  left  bare.     This  applies, 
of  course,  mainly  to  children.     The  laxity  of  the  sub- 
cutaneous tissue  permits  the  organ  to  become  enormously 
swollen  when  cedematous,  or  when  extravasated   urine 
finds  its  way  into  the  part.     Over   the  glans  penis  the 
mucous  membrane  is  so  adherent  that  there  is  practically 
no   subcutaneous   tissue.     It   happens,   therefore,    that 
when  Hunterian  chancres  appear  on  this  part  they  can 
never  be  associated  with  other  than  the  most  trifling 
induration,  there  being  no  tissue  in  which  the  thickening 
can  develop.     At  the  corona,  on  the  other   hand,  the 
submucous  tissue  is  lax  and  plentiful,  so  that  the  in- 
duration can  readily  form,  and  it  is  about  this  spot, 
therefore,  that  the  syphilitic  sore  attains  often  its  most 
characteristic    development,     The    vascularity    of    the 
penis,  and  the  rapid   engorgement  that  ensues  when 
the  return  of  its  venous  blood  is  impeded,  serve  to  explain 
the  ready  and  extensive  swelling  of  the  organ  that  follows 
when  any  constricting  band  is  placed  about  it.      This 
should    be    borne   in    mind  in  tying  in  a  catheter  In- 
securing  it  by  tapes  around  the  penis.     The  blood  spaces 
in  the  corpus  spongiosum  may  be  rendered  indistensible 
from  gonorrheal  inflammation  while  those  of  the  corpora 
cavernosa  remain  free.     The  corpus  spongiosum  then 
acta  like  the  string  of  a  bow  during  the  erection  of  the 


406  Surgical  Applied  Anatomy.  [Chap. xvm. 

psnis.  Through  the  superficial  lymphatics  disease  may 
spread  from  the  skin  and  meatal  region  of  the  penis  to 
the  inner  of  the  inguinal  glands.  Deeper  vessels  pass 
with  the  prostatic  veins  to  the  internal  iliac  group  of 
glands  on  the  lateral  wall  of  the  pelvis.  Some  vessels 
pass  directly  to  the  external  iliac  glands  through  the 
crural  ring.  The  penis  is  often  the  seat  of  arrests  of 
development,  presenting  a  variety  of  appearances. 
Among  them  may  be  mentioned  hypospadias,  where 
the  inferior  wall  of  the  urethra  and  corresponding  part 
of  the  corpus  spongiosum  are  wanting,  and  epispadias, 
where  the  superior  wall  of  the  canal  and  corresponding 
parts  of  the  corpora  cavernosa  are  more  or  less  entirely 
deficient.  The  raphe  along  the  penis,  scrotum,  and 
perineum  marks  the  union  of  the  genital  folds  in  the 
foetus.  These  folds  correspond  to  the  labia  minora 
and  majora  of  the  female.  The  male  urethra  from  the 
sinus  pocularis  to  the  meatus  is  thus  formed. 

Scrotum. — The  skin  of  the  scrotum  is  thin  and 
transparent,  so  that  in  bruising  of  the  parts  the  dis- 
coloration due  to  the  extravasation  of  blood  beneath 
the  surface  is  readily  and  distinctly  seen.  It  is  also 
very  elastic,  and  allows  of  great  distension,  as  is  seen 
in  large  scrotal  hernias  and  testicular  tumours.  The 
integument  of  the  part  is  indeed  redundant,  and  the 
excision  of  a  portion  of  it  will  hardly  be  missed.  Even 
in  gangrene  of  the  scrotum,  when  both  testicles  have 
been  exposed,  the  parts  have  been  entirely  restored 
without  any  inconvenient  shrinking  or  contraction. 
The  rugae  on  the  surface  of  the  scrotum  favour  the 
accumulation  of  dirt,  and  the  irritation  set  up  by  such 
accumulation  may  be  the  exciting  cause  of  the  epi- 
theliomata  that  are  not  uncommon  in  this  part.  When 
the  surface  is  sweating,  the  rugae  tend  to  favour  a 
retention  of  the  moisture  between  their  folds  ;  from 
this  and  other  circumstances  it  happens  that  the 
scrotum  is  liable  to  eczema  and  to  those  syphilitic 
skin  disorders  that  are  often  localised  by  irritation. 
The  rugse  are  a  sign  of  health,  since  they  depend 
upon  the  vigorous  contraction  of  the  muscle  fibres  in 


chap,  xviii.]  The  Pelvis  and  Perineum.  407 

the  dartos  tissue.  In  the  enfeebled,  or  under  the 
relaxing  effects  of  heat,  the  scrotum  becomes  smooth 
and  pendulous.  In  lacerated  wounds,  especially  when 
portions  of  the  skin  are  torn  away,  the  dartos  is  of 
great  value  in  assisting  to  close  the  gap  by  its  contrac- 
tion, and  in  thus  covering  the  exposed  parts.  To  pro- 
mote such  contraction  the  wound  is  dressed  with  cold 
applications.  In  a  simple  incised  wound,  as  in  castra- 
tion, the  dartos  is  apt  to  turn  in  the  edges  of  the  skin 
and  cause  some  difficulty  in  applying  the  sutures. 
This  difficulty  may  be  avoided  by  relaxing  that  tissue 
for  a  while  by  the  application  of  a  warm  sponge  to  the 
wound. 

The  subcutaneous  tissue  is  lax  and  very  extensive, 
and  permits  of  considerable  extravasations  of  blood 
forming  beneath  the  surface.  It  is  unadvisable,  there- 
fore, to  apply  leeches  to  the  scrotum  itself,  since  they 
may  lead  to  an  undesirable  outpouring  of  blood  beneath 
the  skin,  and  to  the  appearance  of  a  considerable 
ecchymosis.  Leeches  in  testicular  affections  had  better 
be  applied  over  the  region  of  the  cord. 

The  scrotum,  from  its  dependent  position,  and  from 
the  looseness  and  extent  of  its  cellular  tissue,  is  often 
the  first  part  of  the  body  to  become  cedematous  in  dropsy, 
and  is  apt  to  show  that  oedema  in  a  marked  degree. 
The  scrotum  also  is  the  part  most  frequently  the  seat  of 
elephantiasis,  which  is  due  essentially  to  a  distension 
of  the  lymphatic  vessels  and  spaces  of  the  connective 
tissue.  The  vitality  of  the  scrotum  is  not  considerable, 
and  it  therefore  not  unfrequently  sloughs  in  parts  when 
severely  inflamed.  For  this  reason  strapping  should 
be  applied  with  some  care  over  the  enlarged  testis,  for 
against  the  hard  mass  of  the  affected  gland  the  integu- 
ment of  the  scrotum  can  be  subjected  to  considerable 
pressure  when  the  strapping  is  tightly  applied.  In  such 
a  case  I  have  seen  the  whole  of  one  side  of  the  scrotum 
slough  from  an  indiscreet  use  of  this  familiar  method 
of  treatment. 

The  laxity  of  the  subcutaneous  scrotal  tissues  is  an 
essential    feature    in    those    operations    for    the    radical 


408  Surgical  Applied  Anatomy.  [Chap,  xviii. 

cure  of  inguinal  hernia  where  the  fundus  of  the  sac  is 
invaginated,  through  an  incision  in  the  scrotum,  into 
the  orifice  of  the  inguinal  canal.  Lastly,  the  great 
mobility  of  the  scrotum  affords  an  admirable  source 
of  protection  to  the  testicle  ;  for  when  the  part  is  struck 
or  squeezed  the  testis  can  slip  about  within  the  scrotum, 
as  a  smooth  ball  would  within  a  loose  indiarubber  bag, 
and  so  very  often  eludes  all  injury. 

The  testicle  may  be  retained  within  the  abdominal 
cavity,  or  may  lodge  for  varying  periods  of  time,  or 
for  life,  in  the  inguinal  canal.  It  may,  on  the  other 
hand,  pass  beyond  the  scrotum  into  the  perineum,  or 
may  miss  the  inguinal  canal  altogether  and  escape 
through  the  femoral  canal  and  saphenous  opening  on 
to  the  thigh.  The  testis  proper  is  entirely  invested 
by  the  visceral  layer  of  the  tunica  vaginalis,  except 
over  a  small  part  of  its  posterior  border  where  the 
vessels  enter.  The  epididymis  is  entirely  covered 
with  the  serous  membrane  at  its  sides,  is  more  or  less 
so  covered  in  front,  but  is  free  or  uncovered  along  the 
greater  part  of  its  posterior  border.  It  is  aboutTthe 
posterior  border  of  the  epididymis  that  the  visceral 
layer  of  the  tunica  vaginalis  joins  the  parietal  layer. 
It  is  mainly  by  this  uncovered  part  of  the  epididymis, 
and  by  the  vessels,  etc.,  that  enter  there,  that  the  testicle 
is  fixed,  for  were  the  whole  organ  to  be  entirely  enveloped 
by  the  serous  membrane,  it  would  lie  more  or  less  loosely 
in  the  serous  cavity  as  lies  the  small  intestine  in  the 
abdomen.  This  condition  occasionally  occurs,  and  in 
such  cases  the  testicle  is  liable  to  strangulation  from 
twisting  on  its  mesentery.  The  more  intimate  and 
extensive  connection  of  the  serous  tunic  with  the  testis 
or  gland  proper  serves  in  part  to  explain  the  greater 
frequency  with  which  hydrocele  appears  in  inflammation 
of  this  part  of  the  organ,  as  compared  with  its  occurrence 
when  the  epididymis  is  alone  inflamed.  It  is  owing  to 
the  reflections  of  the  tunica  vaginalis  that  in  cases  of 
common  hydrocele  the  testicle  remains  firmly  set  at 
the  lower  and  posterior  part  of j  the  swelling,  and  yet  so 
extensively  is^the^organ  surrounded  by[that*membrane 


chap,  xviii.]  The  Pelvis  and  Perineum.  409 

that  the  position  of  the  gland  in  the  larger  hydroceles 
is  often  difficult  to  determine.  In  some  cases  the 
testicle  occupies  the  front  of  the  scrotum,  the  epididymis 
being  placed  anteriorly,  and  the  body  of  the  gland  being 
located  behind  it.  The  vas  deferens  descends  also  along 
the  front  of  the  cord.  In  these  cases  the  testicle  is  just 
in  the  position  it  would  occupy  if  it  had  been  turned 
round  upon  its  vertical  axis.  The  condition  is  known 
as  inversion  of  the  testicle,  and  should  be  sought  for  in 
cases  of  hydrocele,  as  in  several  instances  the  testis  has 
been  pierced  by  the  trochar  when  tapping  collections 
in  which  the  inversion  existed. 

The  proper  gland  tissue  is  invested  by  a  very  dense 
membrane,  the  tunica  albuginea.  The  epididymis,  on 
the  other  hand,  lacks  any  such  firm  fibrous  investment. 
The  unyielding  character  of  the  tunica  albuginea  serves 
in  great  part  to  explain  the  intense  pain  felt  in  acute 
affections  of  the  testis  proper,  a  degree  of  pain  which 
is  not  reached  when  the  less  tightly  girt  epididymis  is 
alone  involved.  It  will  be  understood  also  that  in 
inflammation  of  the  epididymis  the  part  swells  rapidly 
and  extensively,  while  in  a  like  affection  of  the  body 
of  the  gland  the  swelling  is  comparatively  slow  to  appear. 

The  tunica  albuginea  must  also  for  some  time  resist 
the  growth  of  testicular  tumours.  When  the  testicle 
suppurates  and  matter  finds  an  escape  through  the  skin, 
it  is  the  unyielding  character  of  the  tunica  albuginea 
that  is  mainly  answerable  for  any  "  fungus  "  that  may 
form.  This  fungus  merely  means  the  escape  of  swollen, 
softened,  and  inflamed  structures  through  a  hole  in  a 
more  or  less  rigid  membrane,  and  were  that  membrane 
yielding  no  such  protrusion  would  form.  A  "fungus" 
never  develops  in  connection  with  suppuration  of  the 
epididymis  alone  ;  at  the  most  an  abscess  at  that  part 
will  lead  to  a  troublesome  sinus. 

It  should  be  borne  in  mind  that  the  lymphatics 
of  the  scrotum  go  to  the  inguinal  glands,  those  of  the 
testicle  to  the  lumbar.  The  testicle  is  developed  in  front 
of  the  tenth  dorsal  vertebra,  and  receives  its  nerve 
supply  from  the  tenth  dorsal  segment.     Its  nerves  pass 


4i o  Surgical  Applied  Anatomy.  [Chap,  xviii. 

by  the  small  splanchnics,  solar  and  aortic  plexuses,  to 
the  spermatic  artery,  on  which  they  reach  the  gland. 
The  epididymis  receives  its  nerve  supply  from  the  pelvic 
plexus,  along  the  vas  deferens.  In  10  per  cent,  of  cases 
where  castration  of  both  testicles  has  been  performed  in 
adults,  the  operation  was  followed  by  acute  mania. 

The  spermatic  cord§. — The  structures  in  the 
cord  are  (1)  the  vas  deferens,  (2)  the  cremaster  muscle, 
(3)  the  spermatic  and  (4)  cremasteric  arteries,  and 
(5)  the  artery  to  the  vas  deferens,  (6)  the  pampiniform 
plexus  of  veins,  (7)  the  genito-crural  nerve,  (8)  sym- 
pathetic   nerve    fibres,    and    (9)  lymphatics.     The    vas 

yd  DA 

\  / 

Vfov/dftftifik s  A 

&v%2w CA 

■CM 


pr til. 

1 


Fig.  53. — Section  of  the  Left  Spermatic  Cord  of  an  Adult,  at  the  level* 
of  the  External    Abdominal    Ring,    viewed  from   above.      (From   a 
specimen  prepared  by  Mr.  W.  G.  Spencer.) 
vc,   Vas   deferens:     da,    deferential    artery;     dv,    deferential    veins;     .sa 
sparmatic  artery  ;  ca,  cremasteric  artery;  cm,  cremaster  musc.c ;  pp,  para 
piaiform  plexus. 

deferens  lies  along  the  posterior  aspect  of  the  cord  (Fig. 
53),  and  can  be  detected  by  the  firm,  cord-like  sensation 
which  it  gives  when  pinched  between  the  thumb  and 
finger.  Mr.  Birkett  (Holmes'  "  System  ")  gives  three 
cases  of  rupture  of  the  vas  deferens  during  severe  and 
sudden  exertion.  The  duct  appears  to  have  in  each  case 
given  way  within  the  abdomen  at  some  point  between 
the  internal  ring  and  the  spot  where  it  approaches 
the  ureter.  The  injury  is  followed,  as  may  be  supposed, 
by  atrophy  of  the  corresponding  testicle.  Resection 
of  part  of  the  vas  has  been  practised  to  bring  about 
atrophy  of  enlarged  prostate.  The  size  of  the  cre- 
master muscle  depends  mainly  upon  the  weight  it  has  to 


chap,  xvin.]  The  Pelvis  and  Perineum.  411 

suspend.  In  atrophy  of  the  testicle  it  almost  entirely 
disappears,  while  in  cases  of  large  slow-growing  tumours 
of  the  gland  it  attains  considerable  proportions.  If  in 
children  or  young  adults  the  skin  over  the  middle  of  the 
thigh  just  below  Pou  part's  ligament  be  tickled  the  testicle 
of  the  same  side  will  usually  be  seen  to  be  suddenly 
drawn  upwards.  The  tickling  concerns  the  crural 
branch  of  the  genito-crural,  while  the  motor  nerve  of  the 
cremaster  is  the  genital  division  of  the  same  trunk. 
The  interval  of  time  that  elapses  between  the  irritation 
of  the  skin  and  the  movement  of  the  testicle  has  been 
appealed  to  as  affording  evidence  of  the  state  of  nerve 
health  and  of  the  readiness  with  which  nerve  impulses 
are  conducted.  Of  the  arteries,  the  spermatic  comes  from 
the  aorta  and  lies  in  front  of  the  vas,  the  cremasteric 
arises  from  the  deep  epigastric  and  lies  among  the  super- 
ficial layers  of  the  cord  in  its  outer  segment,  while  the 
deferential  artery  from  the  superior  or  inferior  vesical 
lies  by  the  side  of  the  vas  (Fig.  53).  The  first-named 
vessel  is  the  size  of  the  posterior  auricular,  and  the  two 
latter  the  size  of  the  supraorbital.  The  three  arteries  of 
the  cord  are  divided  in  castration,  and  may  all  require 
ligature.  It  is  advisable  to  secure  the  vessels  in  sections, 
rather  than  adopt  the  clumsy  plan  of  involving  the  whole 
cord  in  one  common  ligature.  The  veins  are  divided 
roughly  into  two  sets.  The  anterior  is  by  far  the  larger 
set,  runs  with  the  spermatic  artery,  and  forms  the 
pampiniform  plexus.  The  posterior  set  is  small  and 
surrounds  the  vas,  running  with  the  deferential  artery. 
The  veins  of  the  spermatic  and  pampiniform  plexus 
are  very  frequently  varicose,  and  then  constitute  the 
affection  known  as  varicocele.  Many  anatomical 
causes  render  these  veins  liable  to  this  affection  :  they 
occupy  a  dependent  position,  and  the  main  vein  is  of 
considerable  length,  and  follows  a  nearly  vertical  course  ; 
the  vessels  are  very  large  when  compared  with  the  corre- 
sponding artery,  and  so  the  vis  a  tergo  must  be  reduced 
to  a  minimum  ;  they  occupy  a  loose  tissue,  and  are  lack- 
ing in  support  and  in  the  aid  afforded  to  other  veins 
(as  jn   the  limbs)   by   muscular  contraction  :    they   are 


412  Surgical  Applied  A  na  to  my.  [Cbap.  xvni. 

very  tortuous,  form  many  anastomoses,  and  have  few 
and  imperfect  valves  ;  they  are  exposed  to  pressure 
in  their  passage  through  the  inguinal  canal.  The  left 
veins  are  more  frequently  affected  than  the  right.  Mr. 
Spencer  has  shown  that  the  veins  in  the  left  cord  are 
always  much  larger  than  those  of  the  right.  It  may 
also  be  pointed  out  that  the  left  testicle  hangs  lower  than 
the  right ;  that  the  left  spermatic  vein  enters  the  left 
renal  at  a  right  angle,  while  the  right  spermatic  vein 
passes  obliquely  into  the  vena  cava  ;  and  that  the  left 
vein  passes  beneath  the  sigmoid  flexure,  and  is  thus 
exposed  to  pressure  from  the  contents  of  that  bowel. 
The  congenital  origin  of  varicocele  is  now  very  generally 
allowed. 

When  the  varicose  veins  are  exposed  by  operation  it 
is  impossible  to  isolate  or  even  recognise  the  arteries. 

The  female  generative  organs  require  but 
little  notice  in  the  present  volume.  The  labia  majora 
have  the  same  pathological  tendencies  as  has  the 
scrotum,  to  which,  indeed,  they  anatomically  correspond. 
They  are  liable  to  present  large  extravasations  of  blood, 
are  greatly  swollen  when  oedematous,  are  prone  to 
slough  when  acutely  inflamed,  and  are  the  usual  seats 
of  elephantiasis  in  the  female.  A  hernia  may  present 
in  one  or  other  labium  (pudendal  hernia),  the  neck  of  the 
sac  being  between  the  vagina  and  the  pubic  ramus. 

"  On  everting  one  of  the  labia  minora  and  pressing 
the  hymen  inwards,  a  small  red  depression  may  gener- 
ally be  seen  on  the  vulva,  somewhat  posteriorly.  It  leads 
to  the  orifice  of  Cowpers  duct "  (Doran).  Cowper's 
gland,  an  oval  body  about  ^  an  inch  in  length,  lies 
against  the  posterior  part  of  the  vaginal  orifice,  under 
the  superficial  perineal  fascia,  and  covered  by  the  fibres 
of  the  sphincter  vaginae.  It  wastes  after  thirty. 
Abscess  of  the  gland  and  cystic  dilatation  of  its  duct  are 
not  uncommon. 

The  vagina  is  lodged  between  the  bladder  and  rectum, 
while  the  upper  fourth  of  its  posterior  surface  is  covered 
with  peritoneum,  and  is  therefore  in  relation  to  the 
abdominal  cavity.     Thus  it  happens  that  the  bladder, 


chap,  xviii. i  The  Pelvis  and  Perineum.  413 

the  rectum,  or  the  small  intestines_rnay~protrude  into 
the  vagina  by  a  yielding  of  some  parts  of  its  walls  and 
thus  produce  a  vaginal  cystocele,  rectocele,  or  enterocele. 
The  anterior  wall  of  the  vagina  measures  a  little 
over  2  inches,  the  posterior  wall  about  3  inches.  The 
long  axis  of  the  canal  forms  an  angle  of  60°  with  the 
horizon,  and  is  therefore  almost  parallel  to  the  pelvic 
brim.  The  loose  areolar  tissue  at  the  base  of  the  broad 
ligament  lies  on  each  side  of  the  upper  extremity  of  the 
vagina.  The  ureter  terminates  in  the  bladder,  on  the 
upper  part  of  its  roof. 

The  abdominal  cavity  may  be  opened  through  a 
wound  of  the  vagina.  In  one  or  two  instances  of  such 
injuries  several  feet  of  intestine  have  protruded  through 
the  vulva.  In  one  reported  case  an  old  woman,  the 
subject  of  a  brutal  rape,  walked  nearly  a  mile  with 
several  coils  of  the  small  bowel  hanging  from  her 
genitals. 

From  the  comparative  thinness  of  the  walls  that 
separate  the  vagina  from  the  bladder  and  rectum,  it 
happens  that  vesico-vaginal  and  recto-vaginal  fistulas 
are  of  frequent  occurrence.  The  vagina  is  very  vascular, 
and  wounds  of  its  walls  have  led  to  fatal  haemorrhage. 
It  is  very  dilatable,  as  can  be  shown  when  the  canal 
is  plugged  to  arrest  haemorrhage  from  the  uterus. 

The  uterus  weighs  about  one  ounce.  The  uterine 
cavity  and  the  cervical  canal  together  measure  about 
2 1  inches.  This  must  be  borne  in  mind  when  passing 
a  uterine  sound.  The  blood-vessels  run  transversely 
to  the  length  of  the  uterus,  so  that  a  ligature  may  be 
placed  completely  around  the  organ  without  affecting 
the  circulation  above  or  below.  Ligature  of  the  uterine 
artery  has  been  practised  to  arrest  the  growth  of  uterine 
tumours.  The  artery  rises  from  the  internal  iliac 
£  an  inch  below  the  pelvic  brim  and  passes  to  the  neck 
of  the  uterus  in  the  broad  ligament.  It  is  2|  inches 
long  and  loops  over  the  ureter  midway.  It  is  reached 
by  incising  the  broad  ligament  between  the  Fallopian 
tube  behind  and  the  round  ligament  in  front.  It  is 
found  in  the  loose  areolar  tissue  under   the   wound. 


414  Surgical  Applied  Anatomy.  [Chap.  xvm. 

The  lymphatics  from  the  fundus  of  the  uterus  and 
appendages  pass  to  the  lumbar  glands,  a  few  also  pass 
along  the  round  ligament  to  the  inguinal  glands.  The 
lymphatics  of  the  cervix,  which  is  frequently  the  seat 
of  cancer,  pass  to  the  internal  iliac  glands  on  the  lateral 
wall  of  the  pelvis. 

The  unimpregnated  uterus  is  very  rarely  wounded, 
owing  its  immunity  to  the  denseness  of  its  walls,  to 
its  small  size,  to  its  great  mobility,  and  to  its  position 
within  the  bony  pelvis. 

The  ovary  is  so  placed  that  the  outer  part  of  the 
Fallopian  tube  turns  downwards  external  to  it.  "  Both 
ovaries  lie  in  a  sagittal  plane  against  the  side  walls  of 
the  pelvis,  with  their  long  axes  nearly  vertical;  so 
that  their  surfaces  are  internal  and  external,  borders 
anterior  and  posterior,  and  extremities  upper  and  lower  " 
(Symington).  It  lies  in  the  angle  between  the  external 
and  internal  iliac  arteries  and  may  be  indistinctly  palpated 
through  the  vagina.  Its  nerves  come  from  the  tenth 
dorsal  segment  of  the  cord.  The  sensory  nerves  for 
the  cervix  are  derived  from  the  lower  sacral  segments. 
The  lymphatics  of  the  ovary  pass  to  the  lumbar  glands. 
The  ovaries  exert  atrophic  influence  on  the  breast. 
By  their  removal  it  was  hoped  that  cancer  of  the  breast 
might  be  arrested,  but  the  procedure  has  not  been 
followed  by  much  success.  The  main  ovarian  vessels 
lie  close  to  the  outer  part  of  the  organ,  after  passing 
along  a  short  fold  of  peritoneum,  which  runs  from  the 
brim  of  the  pelvis  to  the  ovary,  and  is  termed  the 
infundibulo-pelvic  ligament.  This  ligament  forms  "the 
outer  part  of  the  pedicle  in  ovariotomy. 

The  rectum  in  the  adult  is  situated  entirely 
within  the  true  pelvis,  and  presents  three  marked  curves, 
one  in  the  lateral  and  two  in  the  antero-posterior 
direction  (see  page  342).  In  the  infant,  however,  a 
good  deal  of  the  rectum  is  in  the  abdominal  rather 
than  the  pelvic  cavity,  the  gut  is  nearly  straight,  and 
occupies  a  more  or  less  vertical  position.  For  these 
reasons,  together  with  the  fact  that  the  sacrum  is  straight, 
the  prostate  small,  and  the  connections  of  the  bowel 


Chap,  xviii.]  The  Pelvis  and  Perineum.  415 

loose,  prolapsus  ani  is  much  more  common  in  children 
than  in  adults.  Children  are,  besides,  especially  liable  to 
such  exciting  causes  of  prolapse  as  worms  and  rectal  polypi. 

The  rectum  is  about  8  inches  in  length.  Its  upper 
part,  for  some  3  inches,  is  entirely  invested  by  peritoneum. 
The  serous  membrane  gradually  leaves  its  posterior 
surface,  then  its  sides,  and  lastly  its  anterior  surface. 
Anteriorly,  the  peritoneum,  in  the  form  of  the  recto- 
vesical pouch,  extends  in  the  male  to  within  3  inches 
of  the  anus,  while  on  the  posterior  aspect  of  the  gut 
there  is  no  peritoneum  below  a  spot  5  inches  from  the 
anus.  Thus,  in  excision  of  the  rectum,  more  of  the 
bowel  can  be  removed  on  the  posterior  than  on  the 
anterior  part  of  the  tube.  It  will  be  seen,  also,  that 
carcinomatous  and  other  spreading  ulcers  are  more 
apt  to  invade  the  peritoneal  cavity  when  they  are  situated 
in  the  anterior  wall  of  the  intestine.  The  internal 
sphincter  surrounds  the  lower  part  of  the  rectum, 
an  inch  above  the  anus,  and  extends  over  about  i  an 
inch  of  the  intestine.  Mr.  Cripps  has  shown  that  the 
posterior  edge  of  the  levator  ani  forms  a  distinctly  felt 
free  border,  which  crosses  the  rectum,  nearly  at  a  right 
angle  at  a  point  from  H  to  2  inches  from  the  anus. 
The  third  stage  of  the  rectum  (anal  canal)  is  firmly 
fixed  by  the  levator  ani  and  is  seldom  involved  in  prolapse 
of  the  rectum. 

By  inserting  the  finger  into  the  rectum  the  prostate 
and  seminal  vesicles  can  be  readily  felt  and  examined, 
and  that  triangular  surface  of  the  bladder  explored 
through  which  puncture  per  rectum  is  made  (page  39  [). 

It  will  be  understood  that  the  prostate,  when 
enlarged,  may  encroach  upon  the  cavity  of  the  rectum 
and  greatly  narrow  its  lumen.  The  position  of  the 
seminal  vesicles  with  regard  to  the  bowel  is  such  that 
in  violent  attempts  at  defalcation  they  may  be  pressed 
upon  by  the  rectal  contents,  and  so  in  part  emptied, 
producing  a  kind  of  spermatorrhoea.  Defamation  also 
often  causes  much  pain  in  inflammatory  affections  of 
the  prostate  and  adjacent  parts. 

The  anterior  surface  of  the   rectum   in   the  female 


416  Surgical  Applied  Anatomy.  [Chap. xviii. 

is  in  relation,  so  far  as  the  finger  can  reach,  with  the 
vagina,  and  in  examining  the  lower  part  of  the  rectum, 
it  is  convenient  to  protrude  its  mucous  membrane 
through  the  anus  by  means  of  the  finger  introduced 
into  the  genital  passage. 

The  rectum  is  dilated,  and  is  very  distensible  just 
above  the  anus.  In  faecal  accumulations  it  may  be 
distended  to  a  considerable  size,  and  strange  foreign 
bodies  of  large  dimensions  have  been  found  in  the 
ampulla.  Among  the  latter  may  be  mentioned  a 
bullock's  horn,  an  iron  match-box,  and  a  glass  tumbler. 
Experiment  has  shown  that  when  the  rectum  is  dis- 
tended in  the  male,  the  recto-vesical  fold  of  peritoneum 
is  raised,  and  the  bladder  is  elevated  and  pushed  forwards. 
In  the  female  the  fundus  uteri  is  raised  and  pushed 
towards  the  symphysis.  The  rectum  is  artificially 
distended  in  suprapubic  lithotomy,  in  order  to  bring 
the  bladder  into  better  position  (page  390). 

If  the  sphincter  be  very  gradually  dilated,  the  entire 
hand,  if  small,  may  be  introduced  into  the  rectum  in 
both  males  and  females.  The  circumference  of  the 
hand  should  not  exceed  8  inches.  By  a  semi-rotary 
movement,  and  by  alternately  flexing  and  extending 
the  fingers,  the  hand  can  be  insinuated  into  the  com- 
mencement of  the  sigmoid  flexure.  Owing  to  the 
mobility  of  this  part  of  the  bowel  a  large  extent  of  the 
abdomen  may  be  explored  through  the  bowel  wall. 
The  structures  that  can  be  readily  felt  are  the  kidney, 
the  aorta,  the  iliac  vessels,  the  uterus  and  ovaries,  the 
bladder  and  its  surroundings,  the  pelvic  brim,  the 
sacro-sciatic  foramina,  the  ischial  cpine,  the  sacrum,  etc. 
In  some  subjects  even  a  small  hand  cannot  be  passed 
beyond  the  reflection  of  the  peritoneum  over  the  second 
part  of  the  gut.  In  such  instances  the  peritoneum 
offers  a  resistance  like  a  tight  garter,  and  prevents 
the  farther  advance  of  the  hand  without  great  risk 
of  laceration  of  the  parts  (Walsham). 

Owing  to  the  constrained  position  of  the  hand  and 
the  cramping  of  the  fingers,  this  method  of  examination 
has  proved  to  be  of  but  limited  service. 


chap,  xvin.]  The  Pelvis  and  Perineum.  417 

Mr.  Davy  has  invented  a  wooden  "  lever,"  by  which 
the  common  iliac  arteries  may  be  compressed  against 
the  pelvic  brim  through  the  rectum.  The  lever  has 
been  used  in  arresting  hemorrhage  during  amputation 
through  the  hip  joint.  The  instrument,  however,  is  of 
little  practical  value. 

The  attachments  of  the  rectum  by  means  of  the  pelvic 
fascia  are  not  very  firm  ;  since,  in  some  severe  and 
rare  cases  of  prolapse,  all  the  walls  of  the  gut  may  be 
protruded  at  the  anus.  In  excision  of  the  rectum, 
also,  advantage  is  taken  of  this  mobility. 

The  mucous  membrane  is  thick,  vascular,  and  but 
loosely  attached  to  the  muscular  coat  beneath.  This 
laxity,  which  is  more  marked  in  children,  favours  pro- 
lapse, an  affection  in  which  the  mucous  membrane  of 
the  lower  part  of  the  rectum  is  protruded  at  the  anus. 
The  mucous  membrane  presents  three  prominent  semi- 
lunar folds,  about  ^  an  inch  in  depth,  which  are  placed 
more  or  less  transversely  to  the  long  axis  of  the  bowel. 
The  first  projects  backwards  from  the  fore  part  of  the 
rectum  opposite  the  prostate,  the  second  projects  inwards 
from  the  left  side  of  the  tube  opposite  the  middle  of 
the  sacrum,  the  third  is  near  the  commencement  of 
the  bowel  on  the  right  side.  These  folds,  especially 
when  the  gut  is  empty,  may  offer  considerable  resistance 
to  the  introduction  of  a  bougie  or  long  enema  tube, 
and  their  position  should  be  therefore  borne  in  mind. 

The  vessels,  and  especially  the  veins,  at  the  lower 
part  of  the  rectum,  are  apt  to  become  varicose  and 
dilated,  and  form  piles.  The  tendency  to  piles  can 
in  part  be  explained  by  the  dependent  position  of  the 
rectum,  by  the  pressure  effects  of  hardened  fasces  upon 
the  returning  veins,  and  by  the  fact  that  part  of  the 
venous  blood  returns  through  the  systemic  system 
(internal  iliac  vein)  and  part  through  the  portal  system 
(inferior  mesenteric  vein).  This  connection  with  the 
portal  trunk  causes  the  rectum  to  participate  in  the  many 
forms  of  congestion  incident  to  that  vein.  The  veins  of  the 
rectum,  also,  can  be  affected  by  violent  expiratory  efforts. 
For  the  last  4  inches,  moreover,  of  the  bowel,  the 
-  u 


4i 8  Surgical  Applied  Anatomy.  [Chap,  xviil 

arrangement  of  the  vessels  is  peculiar,  and  is  such  as  to 
favour  varicosity.  The  arteries,  "  having  penetrated 
the  muscular  coats  at  different  heights,  assume  a  longi- 
tudinal direction,  passing  in  parallel  lines  towards  the 
edge  of  the  bowel.  In  their  progress  downwards  they 
communicate  with  one  another  at  intervals,  and  they 
are  very  freely  connected  near  the  orifice,  where  all 
the  arteries  join  by  transverse  branches  of  considerable 
size  "  (Quain).  The  veins  form  a  plexus  with  a  precisely 
similar  arrangement.  The  veins  beneath  the  mucous 
membrane  of  the  anal  canal  perforate  the  muscular 
coat  of  the  rectum  about  1  inch  above  the  rectum. 
At  the  point  of  perforation  they  are  liable  to  be 
compressed. 

The  lymphatics  of  the  second  and  third  stages  of  the 
rectum  pass  to  the  internal  iliac  group  of  lymphatic 
glands  on  the  lateral  wall  of  the  pelvis.  Hence  in  cancer 
of  the  lower  part  of  the  rectum  these  glands  and  the 
vessels  leading  to  them  are  the  earliest  seats  of  secondary 
infections.  The  lymphatics  of  the  first  stage  pass  to 
the  glands  in  front  of  the  sacrum  and  between  the  layers 
of  the  meso-rectum. 

The  second  and  third  stages  of  the  rectum  may  be 
most  freely  exposed  from  behind  (Fig.  51,  p.  383).  In 
Kraskes  operation  for  the  extirpation  of  cancer  of  the 
rectum  an  incision  is  made  along  the  sacrum  in  the 
middle  line,  from  the  level  of  the  posterior  inferior  iliac 
spines  to  the  anus.  A  flap  is  turned  out  on  the  left  side 
including  the  skin  and  origin  of  the  gluteus  maximus. 
The  attachments  of  the  left  sacro-sciatic  ligaments,  coc- 
cygeus,  and  levator  ani,  to  the  sacrum  and  coccyx  are 
divided  and  turned  outwards.  The  lateral  and  median 
sacral  arteries  and  a  plexus  of  veins  are  raised  with 
the  fibrous  tissue  from  the  anterior  surface  of  the 
sacrum  by  a  periosteal  elevator.  The  left  halves 
of  the  fourth  and  fifth  sacral  vertebras,  with 
the  left  half  of  the  coccyx,  are  removed.  The  fourth, 
fifth  sacral  and  coccygeal  nerves  are  necessarily  cut, 
but  an  attempt  should  be  made  to  save  the  third  sacral 
nerve,  owing  to  the  importance  of  its  function.    The 


Chap,  xvi u.]  The  Pelvis  and  Perineum.  419 

second  and  third  stages  of  the  rectum  are  then  exposed, 
with  the  hemorrhoidal  vessels  and  reflection  of  peri- 
toneum. By  opening  the  peritoneal  cavity  the  greater 
part  of  the  first  stage  of  the  rectum  may  be  brought 
into  the  wound.  After  the  diseased  part  is  removed, 
with  the  presacral  and  internal  iliac  lymphatic  glands, 
the  upper  end  of  the  rectum  is  brought  down  and  sutured 
to  the  anal  part.  An  attempt  should  be  made  to  save 
the  levator  ani  and  third  sacral  nerve,  in  order  that  the 
integrity  of  the  pelvic  diaphragm  be  maintained.  The 
rectum  is  supplied  with  sensory  and  motor  nerves  from 
the  second,  third,  and  fourth  sacral  segments  through 
the  corresponding  nerves.  Some  motor  nerves  are 
also  derived  from  the  lower  two  dorsal  and  upper  lumbar 
segments.  These  nerves  reach  the  rectum  through  the 
hypogastric  and  pelvic  plexuses.  The  stimulus  which 
maintains  the  reflex  act  of  defecation  passes  from  the 
mucous  membrane  of  the  anal  canal. 

Anus* — The  skin  about  the  anus  is  thrown  into 
numerous  folds,  and  it  is  in  these  that  the  ulcer  or  fissure 
of  the  anus  forms.  When  the  anus  is  closed  the  vertical 
columns  of  Morgagni  meet.  At  their  upper  ends  they 
are  united  by  small  valvular  folds  of  membrane,  which 
prevent  the  escape  of  liquid  contents.  These  valves 
may  be  torn  by  the  passing  scybalous  masses,  and  from  the 
rent  thus  caused  a  fissure  of  the  anus  may  be  produced 
(Ball).  The  extreme  painfulness  of  these  ulcers  is  due 
to  the  exposure  of  a  nerve-fibre  at  their  base,  and  to  the 
constant  contraction  of  the  sphincter  muscle  that  they 
excite.  Belief  is  given  by  incising  the  base  of  the  ulcer, 
so  as  to  divide  some  part  of  the  sphincter  ;  or  by  violently 
dilating  the  anus,  so  as  to  tear  up  the  base  of  the  ulcer 
and  paralyse  for  a  while  the  action  of  the  disturbing 
muscle.  A  fine  white  line  around  the  anus,  at  the 
junction  of  the  skin  and  mucous  membrane,  indicates 
the  interval  between  the  external  and  internal  sphincters 
(Hilton). 

The  anus  may  be  torn  during  defecation,  when 
the  stools  are  hard.  A  case  is  reported  of  a  woman 
who,  during  violent  efforts  at  defecation,  felt  something 


420  Surgical  Applied  Anatomy.  [Chap,  xviii. 

give  way,  and  discovered  faeces  in  her  vagina.  The 
recto-vaginal  wall  had  ruptured  2  inches  from  the  anus. 
During  labour  the  child's  head  has  passed  into  the 
rectum,  and  has  been  delivered  per  anum. 

As  congenital  defects,  the  anus  and  entire  rectum 
may  be  absent ;  or  the  anus  be  not  evident,  and  the 
rectum  be  more  or  less  complete  ;  or  the  anus  and 
lowest  part  of  the  rectum  may  be  normal  and  the  upper 
part  of  the  bowel  be  quite  wanting. 

Nerves  ©f  pelvis  and  perineum.  —  The 
pelvic  viscera  are  supplied  by  the  pelvic  plexus  of  the 
sympathetic.  This  plexus  is  joined  by  at  least  three 
spinal  nerves,  the  second,  third,  and  fourth  sacral. 

It  is  well  known  that  in  certain  affections  of  the 
bladder,  rectum,  prostate,  etc.,  pain  is  felt  along  the 
perineum,  in  the  penis,  over  the  buttock,  and  down 
the  thigh.  These  parts  are  supplied  by  the  pudic  and 
small  sciatic  nerves,  and  the  reason  for  the  pain  is  explained 
by  the  origin  of  the  sensory  nerves  for  those  organs 
from  the  same  segments  of  the  spinal  cord.  The  upper 
part  of  the  rectum  is  provided  with  but  little  sensation, 
as  illustrated  by  the  passage  of  instruments,  by  the 
comparative  painlessness  of  malignant  and  other  growths 
high  up  in  the  bowel,  and  by  the  little  inconvenience 
felt  when  the  gut  is  distended  with  hardened  faeces. 
From  this  apathy  it  has  probably  happened  that,  in  the 
self-administration  of  enemata,  patients  have  thrust 
the  tube  through  the  rectum  into  the  peritoneal  cavity. 
The  last  2  inches  of  the  bowel,  on  the  other  hand,  are 
extremely  sensitive. 

The  nerve  relations  between  the  anus  and  the  neck 
of  the  bladder  are  very  intimate.  Painful  affections  of 
the  anus  often  cause  bladder  troubles,  and  retention 
of  urine  is  very  common  after  operations  upon  piles. 
Maladies,  on  the  other  hand,  that  involve  the  bladder 
neck  are  often  associated  with  tenesmus  and  anal  dis- 
comfort. This  relation  is  maintained  by  the  pelvic 
plexus,  but  mainly  by  the  fourth  sacral  nerve.  This 
nerve  gives  special  branches  direct  to  the  neck  of  the 
bladder,  and  then  goes  to  supply  the  muscles  of  the  anus 


Chap,  xviii.]  The  Pelvis  and  Perineum.  421 

(the  sphincter  and  levator)  and  the  integument  between 
the  anus  and  the  coccyx. 

The  mucous  membrane  of  the  urethra,  the  muscles 
of  the  penis,  and  the  greater  part  of  the  skin  of  the  penis, 
scrotum,  perineum,  and  anus,  are  supplied,  from  the 
second,  third,  and  fourth  sacral  segments,  by  the 
pudic  nerve.  Thus,  it  will  be  understood  that 
irritation  applied  to  the  urethra  may  cause  erection 
of  the  penis  (as  illustrated  by  chordee  in  gonorrhoea), 
or  may  produce  contraction  of  the  urethral  muscles 
(as  seen  in  some  forms  of  spasmodic  stricture). 
The  disturbance  caused  by  accumulated  secretion 
beneath  the  prepuce  in  young  children  may  pro- 
voke great  irritability  of  the  organ,  and  it  is  well 
known  that  painful  affections  of  the  perineum  and 
anus  may  be  associated  with  priapism.  The  distribution 
of  the  third  sacral  segment  in  the  perineum  by  means 
of  the  long  pudendal  nerve  will  explain  the  pain  about 
the  buttock  and  down  the  back  of  the  thigh  that  is 
often  complained  of  during  the  growth  of  perineal  abscess 
and  in  painful  affections  of  the  scrotum.  This  nerve 
crosses  just  in  front  of  the  tuber  ischii,  and  may  be 
so  pressed  upon  by  using  a  hard  seat  as  to  cause  one- 
sided neuralgia  of  the  penis  and  scrotum.  It  is  also 
in  close  connection  with  the  ischial  bursa,  and  neuralgia 
of  the  same  parts  has  been  met  with  in  cases  of  inflam- 
mation involving  that  structure. 

The  testicle  is  supplied  mainly  from  the  tenth  dorsal 
segment  by  the  spermatic  plexus.  The  kidney  is  also 
partly  supplied  from  the  same  segment.  This  is  illus- 
trated by  the  pain  felt  in  the  renal  region  in  neuralgia 
of  the  testicle,  by  the  pain  felt  in  the  testicle  and  by 
the  vigorous  retraction  of  that  organ  observed  in  certain 
affections  of  the  kidney,  such  as  in  acute  nephritis,  and 
in  the  passage  of  renal  calculi.  By  means  of  the  renal 
plexus  the  testicle  is  brought  into  direct  communication 
with  the  semi-lunar  ganglia  and  solar  plexus,  which 
receives  some  of  the  terminal  fibres  of  the  vagus.  This 
communication  serves  to  explain  the  great  collapse  often 
noticed  in  sudden  injuries  to  the  testicle,  and  especially 


422  Surgical  Applied  Anatomy.  [Chap,  xviii. 

the  marked  tendency  to  vomit,  so  often  observed  in  such 
lesions.  So  far  as  its  nerves  are  concerned,  the  testicle 
is  nearly  in  as  intimate  relation  with  the  great  nerve- 
centre  of  the  abdomen  as  is  a  great  part  of  the  small 
intestine,  and  one  woiild  expect  a  sudden  crush  of  the 
testis  to  be  associated  with  as  severe  general  symptoms 
as  would  accompany  a  sudden  nipping  of  the  ileum 
in  a  rupture.  Such  a  resemblance  in  symptoms  is 
actually  to  be  observed  in  practice. 


4^3 


prt  V. 

The    Lower    Extremity. 


CHAPTER     XIX. 

THE   REGION    OF   THE   HIP. 

This  region  will  be  considered  under  the  following 
heads:  1.  The  buttocks.  2.  The  region  of  Scarpa's 
triangle.  3.  The  hip  joint.  4.  The  upper  third  of 
the  femur. 

1.  The  buttocks.— Surface  anatomy. — The 
bony  points  about  the  gluteal  region  can  be  well 
made  out.  The  crest  of  the  ilium  is  distinct,  as  is  also 
the  anterior  superior  spine.  The  posterior  superior 
spine  is  less  evident,  but  can  be  readily  felt  by  follow- 
ing the  crest  to  its  posterior  termination.  This  spine 
is  on  a  level  with  the  second  sacral  spine,  and  is  placed 
just  behind  the  centre  of  the  sacro-iliac  articulation. 
The  great  trochanter  is  a  conspicuous  landmark.  It 
is  covered  by  the  fascial  insertion  of  the  gluteal  maxi- 
mus.  Its  upper  border  is  on  a  level  with  the  centre  of 
the  hip  joint,  and  is  somewhat  obscured  by  the  tendon 
of  the  gluteus  medius  which  passes  over  it.  The  com- 
paratively slight  prominence  of  the  trochanter  in  the 
living  subject,  as  compared  with  the  great  projection 
it  forms  in  the  skeleton,  depends  upon  the  completeness 
with  which  the  gluteus  medius  and  minimus  fills  up 
the  hollow  between  the  trochanter  and  the  ilium.  When 
these  muscles  are  atrophied  the  process  becomes  very 
conspicuous.  In  fat  individuals  its  position  is  indicated 
by  a  slight  but  distinct  depression  over  the  hip. 

If  a  line  be  drawn  from  the  anterior  superior  spine 
to  the  most  prominent  part  of  the  tuber  ischii,  it  will 


424  Surgical  Applied  Anatomy.    [Chap.  xix. 

cross  the  centre  of  the  acetabulum,  and  will  hit  the  top 
of  the  trochanter.  This  line,  known  as  Nelaton's  line, 
is  frequently  made  use  of  in  the  diagnosis  of  certain 
injuries  about  the  hip.  For  like  diagnostic  purposes 
Bryant  makes  use  of  a  "  triangle."  As  the  patient  lies 
in  the  recumbent  posture,  a  vertical  line  is  dropped 
from  the  anterior  superior  spine.  A  second  line  is 
drawn  backwards  from  the  same  point  to  the  top  of  the 
great  trochanter.  The  triangle  is  completed  by  a  third 
line  joining  the  first  two,  and  drawn  at  right  angles 
to  the  vertical  line.  A  measurement  of  this  third  or 
test  line  will  show  if  any  shortening  has  taken  place 
in  the  neck  of  the  femur.  It  may  be  noted  that  the 
top  of  the  trochanter  is  nearly  on  a  level  with  the  pubes. 

The  tubera  ischii  are  readily  felt.  They  are  covered 
by  the  fleshy  fibres  of  the  gluteus  maximus  when  the 
hip  is  extended.  But  when  the  hip  is  flexed,  the  pro- 
cesses become  to  a  great  extent  uncovered  by  that 
muscle.  The  muscular  mass  of  the  buttock  is  formed 
by  the  gluteus  maximus  behind  and  by  the  gluteus 
medius  and  minimus  and  tensor  vaginae  femoris  in 
front.  The  latter  muscle  can  be  seen  when  in  action, 
i.e.,  when  the  thigh  is  abducted  and  rotated  in. 

The  fold  of  the  buttock  is  considerably  above  the 
level  of  the  lower  border  of  the  gluteus  maximus,  with 
which  it  therefore  does  not  correspond.  When  the 
hip  is  fully  extended,  as  in  the  erect  posture,  the  but- 
tocks are  round  and  prominent,  the  gluteal  fold  is  trans- 
verse and  very  distinct.  When  the  hip  is  a  little  flexed, 
the  buttocks  become  flattened,  the  gluteal  fold  becomes 
oblique  and  to  a  large  extent  disappears.  Among 
the  early  symptoms  of  hip  disease  are  flattening  of 
the  buttock  and  loss  of  the  gluteal  fold.  These 
symptoms  depend  upon  the  flexion  of  the  hip,  which  is 
practically  constant  in  every  case  of  the  malady  before 
treatment.  It  is  incorrect  to  say,  as  some  books  still 
assert,  that  these  changes  are  due  to  wasting  of  the 
gluteal  muscles,  since  they  appear  at  too  early  a  period  for 
any  considerable  muscular  atrophy  to  have  taken  place. 
It  is  true  that  these  symptoms  are  much  exaggerated 


Chap,  xix.]       The  Region  oe  the  Hip.  425 

by  the  wasting  of  the  muscle  that  occurs  later  on  in  the 
course  of  the  hip  affection. 

With  regard  to  the  vessels  and  nerves  of  the  but- 
tock, if  a  line  be  drawn  from  the  posterior  superior 
spine  to  the  top  of  the  great  trochanter  when  the  thigh 
is  rotated  in,  a  point  at  the  junction  of  the  inner  with 
the  middle  third  of  that  line  will  correspond  to  the 
gluteal  artery  as  it  emerges  from  the  sciatic  notch. 
A  line  drawn  from  the  posterior  superior  spine  to  the 
outer  part  of  the  tuber  ischii  crosses  both  the  posterior 
inferior  and  ischial  spines.  The  former  is  about  2  inches 
and  the  latter  about  4  inches  below  the  posterior  superior 
process.  The  sciatic  artery  reaches  the  gluteal  region 
at  a  spot  corresponding  to  the  junction  of  the  middle 
with  the  lower  third  of  this  line.  The  position  of  the 
pudic  artery  as  regards  the  buttock  is  not  difficult  to 
indicate,  since  it  crosses  over  the  ischial  spine  in 
passing  from  the  great  to  the  small  sacro-sciatic 
foramen. 

A  line  drawn  from  the  point  just  given  for  the  sciatic 
artery  down  the  back  of  the  limb,  so  as  to  lie  about 
midway  between  the  great  trochanter  and  the  ischial 
tuberosity,  will  correspond  to  the  course  of  the  great 
sciatic  nerve. 

The  skin  over  the  buttock  is  thick  and  coarse, 
and  is  frequently  the  seat  of  boils.  From  the  appear- 
ance it  presents  in  very  fully  injected  specimens,  it 
would  appear  that  its  blood  supply  is  not  quite  so  free 
as  it  is  in  many  other  parts  of  the  surface. 

The  subcutaneous  fascia  is  lax,  and  contains  a  large 
quantity  of  fat.  It  is  to  this  fat  rather  than  to  mus- 
cular development  that  the  buttock  owes  its  roundness 
and  prominence.  The  enormous  buttocks  of  the  so- 
called  "  Hottentot  Venus,"  whose  model  is  in  many 
museums,  depend  for  their  unusual  dimensions  upon 
the  greatly  increased  subcutaneous  fat.  The  amount 
of  adipose  tissue  normally  in  the  part  renders  the  buttock 
a  favourite  place  for  lipomata.  The  laxity  of  the  super- 
ficial fascia  permits  large  effusions  both  of  blood  and 
pus  to  take'place  in  the  gluteal  region,  and  ecchymoses 


426  Surgical  Applied  Anatomy.    [Chap.  xix. 

of  the  buttock  can  probably  reach  a  greater  magnitude 
than  is  possible  elsewhere. 

The  deep  fascia  of  the  buttock,  a  part  of  the 
fascia  lata  of  the  thigh,  is  a  structure  of  much 
importance.  This  dense  membrane  is  attached  above 
to  the  iliac  crest,  and  to  the  sacrum  and  coccyx.  De- 
scending in  front  over  the  gluteus  medius,  it  splits 
on  reaching  the  anterior  edge  of  the  gluteus  maximus 
into  two  layers,  one  of  which  passes  in  front  of  the 
muscle  and  the  other  behind.  The  gluteus  maximus 
is  thus  enclosed,  like  the  meat  in  a  sandwich,  between 
two  layers  of  fascia,  and  the  two  lesser  gluteal  muscles 
are  bound  down  within  an  osseo-aponeurotic  space, 
which  is  firmly  closed  above,  and  only  open  below 
towards  the  thigh  and  internally  at  the  sciatic  fora- 
mina. Extra  vacations  of  blood  may  take  place  beneath 
this  fascia  without  any  discoloration  of  the  skin  to 
indicate  the  fact,  the  blood  being  unable  to  reach  the 
surface  through  the  dense  membrane.  Such  extravasa- 
tions may  be  long  pent  up,  and,  as  they  would  fluctuate, 
may  be  mistaken  for  abscess. 

Deep  inflammations  beneath  this  fascia,  and  especi- 
ally when  beneath  the  gluteus  medius,  may  be  associated 
with  much  pain,  owing  to  the  circumstance  that  the 
inflammatory  effusions  will  be  pent  up  between  a  wall 
of  bone  on  one  side  and  a  wall  of  dense  fascia  and  stout 
muscle  on  the  other.  Abscesses  so  pent  up  may  travel 
for  a  considerable  distance  down  the  thigh  before  they 
reach  the  surface,  and  Farabeuf  relates  a  case  where  a 
gluteal  abscess  travelled  to  the  ankle  before  it  broke. 

Under  other  circumstances  the  gluteal  abscess  may 
make  its  way  into  the  pelvis  through  the  sciatic  foramina, 
or  a  pelvic  abscess  may  escape  through  one  of  these 
foramina  and  appear  as  a  deep  abscess  of  the  buttock. 

The  thickened  part  of  the  fascia  lata  that  runs  down 
on  the  outer  side  of  the  limb,  between  the  crest  of  the 
ileum  above  and  the  outer  tuberosity  of  the  tibia  and 
head  of  the  fibula  below,  is  known  as  the  ilio-tibial  band. 
This  band  is  tightly  stretched  across  the  gap  between 
the  iliac  crest  and  the  great  trochanter,  and  if  pressure 


chap,  xix.]       The  Region  of  the  Hip.  427 

be  made  with  the  fingers  between  these  two  points, 
the  resistance  of  this  part  of  the  fascia  can  be  appreciated. 
It  is  obvious  that  in  fracture  of  the  neck  of  the  femur, 
when  the  great  trochanter  is  made  to  approach  nearer 
to  the  crest,  this  band  will  become  relaxed,  and  Dr.  Allis 
(Agnew's  "  Surgery,"  vol.  i.)  has  drawn  attention  to  this 
fascial  relaxation  as  of  value  in  the  diagnosis  of  fractures 
of  the  femoral  neck. 

The  lower  free  edge  of  the  gluteus  maxiiiius  is 
oblique,  and  is  some  way  below  the  transverse  line  of 
the  fold  of  the  buttock. 

It  would  appear  that  even  this  great  muscle  may 
be  ruptured  by  violence.  Thus  Dr.  MacDonnell  (Brit. 
Med.  Journ.,  1878)  reports  the  case  of  a  robust  man, 
aged  sixty-three,  who,  while  trying  to  lift  a  heavy  cart 
when  in  a  crouching  position,  felt  something  give  way 
in  his  buttock,  and  heard  a  snap.  He  fell,  and  was 
carried  home,  when  it  was  found  that  the  great  gluteal 
muscle  was  ruptured  near  the  junction  with  its  tendon. 

At  least  three  I>ufi*sae  exist  over  the  great 
trochanter,  separating  that  process  from  the  three 
gluteal  muscles  respectively.  The  most  important  of 
these  is  the  bursa  between  the  gluteus  maximus  and 
the  bone.  When  this  sac  is  inflamed  much  difficulty 
is  experienced  in  moving  the  limb,  and  the  thigh  is 
generally  kept  flexed  and  adducted.  This  position 
means  absolute  rest  from  movement  on  the  part  of  the 
gluteal  muscles,  which,  when  acting,  would  extend 
and  abduct  the  limb,  and  bring  pressure  to  bear  upon 
the  tender  bursa. 

The  bursa  is  quite  close  to  the  bone,  so  close  that 
it  is  said  that  caries  of  the  trochanter  has  followed  upon 
suppuration  of  the  little  sac  (T  .P.  Teale).  There  is  a 
bursa  over  the  ischial  tuberosity  that  is  often  inflamed 
in  those  whose  employments  involve  much  sitting, 
the  bursa  being  directly  pressed  upon  in  that  position. 
This  sac  is  the  anatomical  basis  of  the  disease  known 
in  older  text-books  as  "  weaver's  bottom,"  or  "  lighter- 
nun's  bottom."  When  enlarged  this  bursa  may  press 
upon  the  inferior  pudendal  nerve. 


428  Surgical  Applied  Anatomy,   tchap.  xix. 

The  arteries  and  nerves  of  the  buttock. — 

The  gluteal  artery  is  about  the  same  size  as  the  ulnar, 
and  the  sciatic  as  the  lingual.  The  former  vessel  may 
sometimes  be  of  much  greater  magnitude,  and  has 
led,  when  wounded,  to  rapid  death  from  haemorrhage. 
Wounds  of  the  gluteal  vessels  will  probably  involve 
only  the  branches  of  the  artery,  since  the  greater  part 
of  the  main  trunk  is  situate  within  the  pelvis.  Gluteal 
aneurisms  are  not  very  uncommon,  and  with  regard 
to  the  treatment  of  these  tumours  it  may  be  noted  that 
the  gluteal  artery,  or,  better,  the  internal  iliac  trunk, 
can  be  compressed  through  the  rectum.  Compression 
so  applied  has  been  adopted  for  the  treatment  of  gluteal 
aneurism  by  Dr.  Sands,  of  New  York  (Amer.  Journ.  Med. 
Sc,  1881),  but  without  much  effect.  Aneurism  of 
the  commencement  of  the  gluteal  artery  could  hardly 
fail  to  provoke  nerve  symptoms,  since  the  vessel  runs 
between  the  lumbo-sacral  cord  and  first  sacral  nerve. 

Both  the  gluteal  and  sciatic  arteries  have  been 
ligatured  through  the  buttock,  through  incisions  made 
directly  over  the  course  of  the  vessels. 

Henle  has  collected  six  cases  where  the  femoral 
artery  ran  down  along  the  back  of  the  thigh  to  the 
popliteal  space  in  company  with  the  great  sciatic  nerve. 
The  abnormal  vessel  was  in  each  case  continued  from 
a  greatly  enlarged  sciatic  artery. 

The  great  sciatic  nerve  is  a  continuation 
downwards  of  the  main  part  of  the  sacral  plexus.  It 
is  in  this  nerve  that  the  form  of  neuralgia  known  as 
sciatica  is  located.  A  reference  to  the  immediate 
relations  of  this  nerve  will  show  that  it  may  readily 
be  exposed  to  many  external  influences.  Thus,  in  the 
pelvis  it  may  be  pressed  upon  by  various  forms  of  pelvic 
tumour,  and  sciatica  be  produced  in  consequence.  Its 
anterior  surface  is  in  close  relation  with  some  of  the 
principal  pelvic  veins,  and  according  to  Erb  one  form 
of  sciatica  may  be  traced  to  an  engorged  condition  of 
these  vessels.  Aneurism  of  certain  branches  of  the 
internal  iliac  artery  within  the  pelvis,  sciatic  hernia, 
and  accumulation  of  faeces  within  the  rectum,  may  all 


Chap,  xix.j       The  Region  of  the  Hip.  429 

cause  neuralgia  of  this  important  trunk.  It  is  said  to 
have  been  injured  also  by  the  pressure  of  the  foetal  head 
during  tedious  labours,  and  to  be  affected  by  violent 
movements  of  the  hip,  a  circumstance  readily  under- 
stood if  the  close  relation  of  the  nerve  to  the  hip-joint 
be  borne  in  mind.  The  nerve  is  also  near  enough  to 
the  surface  to  be  influenced  by  external  cold,  and  to 
this  influence  many  forms  of  sciatica  are  ascribed.  At 
the  lower  edge  of  the  great  gluteal  muscle  the  trunk 
is  still  nearer  to  the  surface,  and  this  fact  receives 
illustration  in  a  case  reported  in  Ziemssen's  Cyclopaedia, 
where  paralysis  of  the  nerve  followed  its  compression 
by  the  contracting  scar  of  a  bed-sore. 

Nerve  stretching:.— The  great  sciatic  nerve  has 
been  frequently  cut  down  upon  and  stretched  for  the 
relief  of  certain  nervous  affections  of  the  limb.  In 
connection  with  this  procedure  it  is  important  to  know 
how  great  an  amount  of  traction  may  be  brought  to 
bear  upon  this  and  other  nerves  without  the  cord  giving 
way.  Trombetta,  who  has  paid  much  attention  to 
this  matter,  gives  the  following  weights  as  those  required 
to  break  the  undermentioned  nerves :  great  sciatic, 
183  pounds;  internal  popliteal,  114  pounds;  anterior 
crural,  83  pounds ;  median,  83  pounds  ;  ulnar  and 
radial,  59  pounds  ;  brachial  plexus  in  the  neck,  48  to 
63  pounds  ;  and  brachial  plexus  in  the  axilla,  35  to 
81  pounds.  (In  each  instance  fractions  have  been 
omitted.)  It  must  be  borne  in  mind,  however,  as  pointed 
out  by  Mr.  Symington  {Lancet,  1878),  that  in  forcibly 
stretching  the  great  sciatic  nerve  the  trunk  may  be 
torn  away  from  its  attachments  to  the  soft  spinal  cord 
before  a  sufficient  force  has  been  applied  to  rupture 
the  nerve  at  the  point  stretched.  The  same  observation 
applies  to  other  large  nerve-cords,  such  as  those  of  the 
brachial  plexus,  that  are  stretched  at  a  spot  not  far 
from  their  spinal  connections.  The  great  sciatic  nerve 
may  be  stretched  by  flexing  the  extended  lower  extremity 
on  the  belly.  This  measure  has  served  to  cure  certain 
cases  of  sciatica. 

The  skin  of  the  buttock  is  well  supplied  with  nerves, 


43°  Surgical  Applied  Anatomy.   [Chap.  xix. 

and  tactile  sensibility  is  almost  as  acute  in  this  part 
as  it  is  over  the  back  of  the  hand,  while  it  is  more  acute 
than  is  like  sensibility  in  such  parts  as  the  back  of  the 
neck,  the  middle  of  the  thigh,  and  the  middle  of  the 
back.  The  sensation  of  the  gluteal  integument  is 
derived  from  a  number  of  different  nerves,  and  it  may 
possibly  interest  a  school-boy  who  has  been  recently 
birched  to  know  that  the  painful  sensations  reached 
his  sensorium  through  some  or  all  of  the  following  nerves  : 
offsets  of  the  posterior  branches  of  the  lumbar  nerves, 
some  branches  of  the  sacral  nerves,  the  lateral  cutaneous 
branch  of  the  last  dorsal  nerve,  the  iliac  branch  of  the 
ilio-hypogastric  nerve,  offsets  of  the  external  cutaneous 
nerve,  and  large  branches  of  the  small  sciatic.  These 
nerves  are  derived  from  four  spinal  segments — the 
twelfth  dorsal,  first  lumbar,  second  and  third  sacral 
(Fig.  78,  p.  534).  The  second  and  third  sacral  also 
supply  the  sexual  organs,  hence  the  physiological 
effects  which  may  follow  application  of  punishment  to 
this  part,  as  in  the  celebrated  case  of  J.  J.  .Rousseau. 

It  should  be  remembered  that  the  pelvic  viscera 
can  be  readily  reached  through  the  sciatic  foramina 
from  the  buttock.  I  once  saw  a  case  at  the  London 
Hospital  of  a  man  who  was  admitted  with  an  apparently 
insignificant  stab  of  the  buttock.  He  died  in  a  few 
days,  of  acute  peritonitis  ;  and  the  autopsy  showed 
that  the  dagger  had  passed  through  the  great  sacro- 
sciatic  foramen,  had  entered  the  bladder  and  allowed 
urine  to  escape  into  the  peritoneal  cavity.  The  rectum 
has  also  been  damaged  in  injuries  to  the  buttock,  and 
Anger  records  a  case  of  an  artificial  anus  situate  upon 
the  buttock,  that  had  followed  a  gunshot  wound,  which, 
after  involving  the  buttock,  had  opened  up  the  caecum. 
It  is  by  this  route  that  Kraske's  operation  for  resection 
of  the  rectum  is  performed. 

2.  The  region  of  Scarpa's  triangle. — 
Surface  anatomy. — The  most  important  landmarks 
in  the  region  of  the  groin,  the  anterior  superior  iliac 
spine,  the  spine  of  the  pubes,  and  Poupart's  ligament, 
are   readily   made   out.     To   the   two   spines   reference 


Chap.  xix. j       The  Region  of  the  Hip.  431 

has  already  been  made  (page  423).  Poupart's  ligament 
follows  a  curved  line,  with  its  convexity  downwards, 
drawn  between  these  two  projections.  It  can  be  felt 
in  any  but  stout  persons,  its  inner  half  more  distinctly 
than  its  outer,  and  even  in  very  fat  individuals  its 
position  is  indicated  by  a  slight  furrow.  Owing  to  its 
attachment  to  the  fascia  lata  the  ligament  is  relaxed, 
and  rendered  less  distinct  when  the  thigh  is  flexed  and 
adducted,  or  when  it  is  rotated  in. 

The  line,  often  called  "  Holden's  line,"  is  thus 
described  by  that  surgeon :  "  When  the  thigh  is  even 
slightly  bent,  there  appears  a  second  furrow  in  the 
skin,  below  that  at  the  crural  arch.  This  second  furrow 
begins  at  the  angle  between  the  scrotum  and  the  thigh, 
passes  outwards,  and  is  gradually  lost  between  the  top 
of  the  trochanter  and  the  anterior  superior  spine  of  the 
ilium.  It  runs  right  across  the  front  of  the  capsule 
of  the  hip-joint.  For  this  reason  it  is  a  valuable  land- 
mark in  amputation  at  the  hip-joint.  The  point  of  the 
knife  should  be  introduced  externally  where  the  furrow 
begins,  should  run  precisely  along  the  line  of  it,  and 
come  out  where  it  ends  ;  so  that  the  capsule  of  the  joint 
may  be  opened  with  the  first  thrust.  .  .  .  Effusion 
into  the  joint  obliterates  all  trace  of  the  furrow,  and 
make  a  fulness  when  contrasted  with  the  opposite  groin." 
It  must  be  confessed  that  this  line  is  not  always  so  dis- 
tinct as  Mr.  Holden's  description  would  lead  us  to  believe, 
and  in  many  subjects  it  is  quite  impossible  to  make  it  out 
at  all. 

The  sartorius  muscle  is  brought  into  view  when 
the  leg  is  raised  across  the  opposite  knee,  and  the 
adductor  longus  is  rendered  distinct  when  the  thigh 
is  abducted,  and  the  individual's  attempts  to  adduct 
the  limb  are  resisted.  Even  in  the  obese  the  clear 
edge  of  this  muscle  can  be  felt  when  it  is  in  vigorous 
action,  and  the  fingers  can  follow  its  border  up  to  the 
very  origin  of  the  muscle,  just  below  the  pubic  spine. 

The  lymphatic  glands  in  this  region  can  sometimes 
be  felt  beneath  the  skin,  especially  in  thin  children. 
The  femoral  rin£  lies  on  a  horizontal  line  drawn  from 


432  Surgical  Applied  Anatomy.    [Chap.  xix. 

the  pubic  spine  to  the  top  of  the  great  trochanter,  at 
about  1  inch  to  the  outer  side  of  the  first-named  process  ; 
or  its  position  may  be  indicated  by  noting  the  pulsations 
of  the  femoral  artery  against  the  pubes  ;  and  then, 
by  allowing  \  an  inch  to  the  inner  side  of  that  vessel 
for  the  femoral  vein,  the  site  of  the  femoral  ring  will  be 
reached.  The  position  of  the  saphenous  opening  is 
sometimes  indicated  by  a  slight  depression  in  the  integu- 
ments. It  lies  just  below  Poupart's  ligament,  and  its 
centre  is  about  1  \  inches  below  and  external  to  the  pubic 
spine.  In  thin  subjects  the  long  saphenous  vein  can 
be  often  made  out,  passing  to  the  saphenous  opening. 

If  a  line  be  drawn  from  a  point  just  to  the  inner 
side  of  the  middle  of  Poupart's  ligament  to  the  tubercle 
for  the  adductor  magnus,  on  the  inner  condyle  of  the 
femur,  when  the  thigh  is  slightly  flexed  and  abducted, 
it  will  correspond  in  the  upper  two-thirds  of  its  extent 
to  the  position  of  the  femoral  artery.  Just  below 
Poupart's  ligament  the  femoral  vein  lies  to  the  inner 
side  of  the  artery,  while  the  anterior  crural  nerve  runs 
about  \  of  an  inch  to  its  outer  side.  The  profunda 
femoris  arises  about  \\  inches  below  Poupart's  ligament, 
and  the  internal  and  external  circumflex  vessels  come 
off  about  2  inches  below  that  structure. 

The  head  of  the  femur  lies  close  below  the  ligament, 
and  just  to  the  outer  side  of  its  central  point.  In  very 
thin  subjects  this  part  of  the  bone  can  be  indistinctly 
felt  through  the  soft  parts  when  the  thigh  is  extended 
and  rotated  outwards. 

The  skin  over  Scarpa's  triangle  is,  unlike  that  of 
the  buttock,  comparatively  thin  and  fine.  The  loose- 
ness of  its  attachment,  also,  to  the  parts  immediately 
beneath,  permits  it  to  be  greatly  stretched,  as  is  seen 
in  cases  of  large  femoral  hernise,  and  in  certain  inguinal 
tumours  of  large  size.  It  may  even  give  way  under 
severe  traction,  as  occurred  in  a  case  reported  by  Berne. 
The  patient  in  this  case  was  a  child  aged  11,  the  subject 
of  hip  disease.  The  thighs  were  flexed  upon  the  ab- 
domen, and,  forcible  extension  being  applied  to  relieve 
the  deformity,  the  skin  gave  way  just  below  the  groin, 


Chap,  xix.]       The  Region  of  the  Hip.  433 

and  separated  to  the  extent  of  some  2^  inches.  Con- 
tracting scars  in  the  region  of  the  groin  may  produce 
a  permanent  flexing  of  the  hip,  and  this  result  is  not 
uncommon  after  deep  and  severe  burns  this  neigh- 
bourhood. It  may  at  the  same  time  be  noted  that 
horizontal  wounds  about  the  groin  can  be  well  adjusted 
by  a  slight  flexion  of  the  thigh. 

Instances  are  recorded  where  a  supernumerary 
mammary  gland,  provided  with  a  proper  nipple,  has 
been  found  located  in  the  groin.  Jessieu  relates  the 
case  of  a  female  who  had  a  breast  so  placed,  and  who 
suckled  her  child  from  this  part.  (See  page  178.)  In 
a  few  cases  the  testicle,  instead  of  descending  into  the 
scrotum,  has  escaped  through  the  crural  canal,  and 
made  its  appearance  in  Scarpa's  triangle.  It  has  even 
mounted  up  over  Poupart's  ligament  after  the  manner 
of  a  femoral  hernia,  being  probably  urged  in  that  direc- 
tion by  the  movements  of  the  limb. 

The  superficial  fascia  in  this  region  is  not 
very  dense,  and  has  little  or  no  influence  upon  the 
progress  of  a  superficial  abscess.  This  fact  receives 
extensive  illustration,  since  the  glands  in  Scarpa's  tri- 
angle frequently  suppurate,  and  yet  the  pus  in  the 
great  majority  of  the  cases  readily  reaches  the  surface 
in  spite  of  the  circumstance  that  the  denser  layer  of  the 
superficial  fascia  (for  in  this  region  it  is  divided  into 
two  layers)  covers  in  those  glands,  and  should  hinder 
the  progress  of  pus  towards  the  surface.  Although 
the  subcutaneous  fat  is  not  peculiarly  plentiful  in  this 
region,  yet  Scarpa's  triangle  is  a  favourite  spot  for 
lipomata.  It  is  in  this  place  that  the  fatty  tumour 
often  exhibits  its  disposition  to  travel,  and  several  cases 
are  reported  where  such  a  tumour  has  started  at  the 
groin,  and  travelled  some  way  down  the  thigh.  The 
journey  is  always  in  the  direction  of  gravity,  and 
rendered  possible  by  the  lax  capsule  of  the  tumour,  by 
the  looseness  of  the  tissue  in  which  it  is  embedded,  and  by 
the  fluidity,  of  fat  at  the  normal  temperature  of  the  body. 
The  fascia  lata  completely  invests  the  limb, 
being,  so  far  as  the  front  of  the  thigh  is  concerned 


434  Surgical  Applied  Anatomy.   [Chap.  xix. 

attached  above  to  Poupart's  ligament,  to  the  body  and 
ramus  of  the  pubes,  and  the  ramus  of  the  ischium.  Its 
integrity  is  interrupted  only  by  the  saphenous  opening. 
This  fascia  exercises  some  influence  upon  deep  abscesses 
and  deep  growths.  Thus  a  psoas  abscess  reaches  the 
thigh  by  following  the  substance  of  the  psoas  muscle, 
and  finds  itself,  when  it  arrives  at  Scarpa's  triangle, 
under  the  fascia  lata.  In  a  great  number  of  cases  it 
points  where  the  psoas  muscle  ends,  but  in  other  and 
less  frequent  instances  its  progress  is  decidedly  influenced 
by  the  fascia  lata,  and  it  moves  down  the  limb.  Thus 
guided,  a  psoas  abscess  has  pointed  low  down  in  the  thigh, 
and  even  at  the  knee,  and  Erichsen  reports  a  case  where 
such  an  abscess  (commencing,  as  it  did,  in  the  dorsal 
spine)  was  ultimately  opened  by  the  side  of  the  tendo 
Achillis. 

The  ilio-psoas  muscle,  being  stretched,  as  it  were, 
over  the  front  of  the  hip  joint,  and  participating  in 
many  of  the  movements  of  that  joint,  is  peculiarly 
liable  to  be  sprained  in  violent  exercises.  Between 
this  muscle  and  the  thinnest  part  of  the  hip  capsule 
is  a  bursa,  which  often  communicates  with  the  joint. 
When  chronically  inflamed,  this  bursa  may  form  a  large 
tumour  on  the  front  of  the  thigh  that  may,  accord- 
ing to  Nancrede,  attain  the  size  of  a  child's  head.  To 
relieve  this  bursa  from  pressure  when  inflamed,  the 
thigh  always  becomes  flexed,  and  a  train  of  symptoms 
is  produced  that  are  not  unlike  those  of  hip  disease. 

The  bursa  is  quite  close  to  the  pelvic  bones,  and  in  one 
case  at  least  suppuration  of  this  bursa  led  to  necrosis 
of  those  bones  (Nancrede).  The  deep  origins  of  the  ilio- 
psoas lie  behind  the  caecum  and  kidney,  and  may  elicit 
symptoms  from  those  organs  when  contracted.  The 
sartorius  is  a  muscle  that,  from  its  length,  peculiar  action, 
etc.,  one  would  hardly  expect  to  find  ruptured  from 
violence,  yet  in  the  Musee  Dupuytren  there  is  a  specimen 
of  such  a  rupture  about  the  middle  of  the  muscle  united 
by  fibrous  tissue.  The  adductor  muscles,  and  especially 
the  adductor  longus,  are  frequently  sprained,  or  even 
partially  ruptured,  during  horse  exercise,  the  grip  of 


Chap,  xix.j       The  Region  of  the  Hip.  435 

the  saddle  being  for  the  most  part  maintained  by 
them.  "  Rider's  sprains,"  as  such  accidents  are  called, 
usually  involve  the  muscles  close  to  their  pelvic  attach- 
ments. Much  blood  is  often  effused  when  the  fibres 
are  ruptured,  and  such  effusion  may  become  so  dense 
and  fibrinous  as  to  form  a  mass  that  has  been  mistaken 
for  a  detached  piece  of  the  pubes  (Henry  Morris).  The 
term  "  rider's  bone  "  refers  to  an  ossification  of  the  upper 
tendon  of  the  adductor  longus  or  magnus,  following  a 
sprain  or  partial  rupture.  Cases  are  reported  where 
the  piece  of  bone  in  the  tendon  was  \  an  inch,  2  inches, 
and  even  3  inches  long. 

Blood-vessels. — The  femoral  artery  occupies  so 
superficial  a  position  in  Scarpa's  triangle  that  it  is  not 
unfrequently  wounded.  The  vessel  also  has  been 
opened  up  by  cancerous  and  phagedaenic  ulcerations  of 
this  part,  the  occurrence  leading  to  fatal  haemorrhage. 
Pressure  is  most  conveniently  applied  to  the  artery  at 
a  spot  immediately  below  Poupart's  ligament,  and 
should  be  directed  backwards,  so  as  to  compress  the 
vessel  against  the  pubes  and  adjacent  parts  of  the  hip 
capsule.  Lower  down,  compression  should  be  applied 
in  a  direction  backwards  and  outwards,  so  as  to  bring 
the  artery  against  the  shaft  of  the  femur,  which  lies 
at  some  distance  to  its  outer  side.  Pressure  rudely 
applied  by  a  tourniquet  may  cause  phlebitis  by  damaging 
the  vein,  or  neuralgia  by  contusing  the  anterior  crural 
nerve. 

From  the  near  proximity  of  the  artery  and  vein, 
it  happens  that  arterio-venous  aneurisms  following 
wound  have  been  met  with  in  this  situation.  Aneur- 
ism is  frequent  in  the  common  femoral,  and  many 
reasons  can  be  given  why  that  vessel  should  be  attacked. 
It  i3  just  about  to  bifurcate  into  two  large  trunks,  its 
superficial  position  exposes  it  to  injury,  it  is  greatly 
influenced  by  the  movements  of  the  hip,  and  its  coat 
may  even  be  damaged  by  those  movements,  if  excessive. 

Phlebitis  of  the  femoral  vein  has  in  many  cases 
followed  contusion  of  the  vessel  in  its  upper  or  more 
superficial  part,  and  a  like  result    bag  even  followed 


436  Surgical  Applied  Anatomy.  [Chap.  xix. 

from  violent  flexion  of  the  thigh.  The  long  saphenous 
vein  is  often  varicose,  and  one  form  of  the  varicosity 
is  said  to  depend  upon  constriction  of  the  vein  by  an 
unduly  narrow  saphenous  opening.  One  sometimes 
meets  with  cases  that  may  probably  be  due  to  this  cause  ; 
but  the  evidence  is  not  sufficient  to  sanction  the  opera- 
tion proposed  for  such  cases,  viz.,  an  enlargement  of 
the  saphenous  opening  itself.  That  varicose  veins  are, 
in  the  majority  of  cases,  of  congenital  origin  is  now 
very  generally  allowed. 

The  anterior  crural  nerve  lies  on  the  ilio-psoas 
muscle,  and  it  is  said  that  neuralgia,  and  even  paralysis 
of  the  nerve,  may  follow  upon  inflammation  of  that 
muscle  and  upon  psoas  abscess.  The  superficial  position 
of  the  trunk  exposes  it  to  injury.  The  genito-crural 
nerve  (the  nerve  that  supplies  the  cremaster  muscle) 
gives  a  sensory  filament  to  the  integument  of  the  thigh 
in  Scarpa's  triangle.  Irritation  of  the  skin  over  the 
seat  of  this  nerve,  which  is  placed  just  to  the  outer  side 
of  the  femoral  artery,  will  cause,  in  children,  a  sudden 
retractation  of  the  testicle.  The  same  result  is  often 
S3en  in  adults,  also,  on  more  severe  stimulation.  In 
this  manner  the  condition  of  the  second  lumbar 
segment  of  the  cord  may  be  tested. 

The  lymphatic  glands  in  this  region  are 
numerous,  and  as  they  are  frequently  the  seat  of  abscess, 
it  is  important  to  know  from  whence  they  derive  their 
afferent  vessels.  They  are  divided  into  a  superficial 
and  deep  set.  The  superficial  set,  averaging  from  ten 
to  fifteen  glands,  are  arranged  in  two  clusters,  one 
parallel  and  close  to  Poupart's  ligament  (the  horizontal 
series),  the  other  parallel  and  close  to  the  long  saphenous 
vein  (the  vertical  series).  The  deep  set,  about  four  in 
number,  are  placed  along  the  femoral  vein,  and  reach 
the  crural  canal. 

The  inguinal  glands  receive  the  following  lymphatics  : 

Superficial  vessels  of  lower  limb  =  vertical  set  of 
superficial  glands. 

Superficial  vessels  of  lower  half  of  abdomen  — 
middle  glands  of  horizontal  set. 


chap,  xix.]       The  Region  of  the  Hip.  437 

Superficial  vessels  from  outer  surface  of  buttock  = 
external  glands  of  horizontal  set. 

From  inner  surface  of  buttock  =  internal  glands 
of  horizontal  set.  (A  few  of  these  vessels  go  to  the 
vertical  glands.) 

Superficial  vessels  from  external  genitals  =  hori- 
zontal glands,  some  few  going  to  vertical  set. 

Superficial  vessels  of  perineum  =  vertical  set. 

Deep  lymphatics  of  lower  limb  =  deep  set  of 
glands. 

The  lymphatics  that  accompany  the  obturator, 
gluteal,  and  sciatic  arteries,  and  the  deep  vessels  of  the 
penis,  pass  to  the  pelvis  and  have  no  concern  with  the 
inguinal  glands. 

One  of  the  deep  glands  lies  in  the  crural  canal  and 
upon  the  septum  crurale.  Being  surrounded  by  dense 
structures,  it  is  apt  to  cause  great  distress  when  inflamed 
and  great  pain  when  the  hip  is  moved.  In  some  cases, 
by  reflex  disturbance,  it  has  produced  symptoms  akin 
to  those  of  strangulated  hernia.  Some  branches  of  the 
anterior  crural  nerve  lie  over  the  inguinal  lymph  glands, 
and  Sir  B.  Brodie  reports  a  case  in  which  these  branches 
were  stretched  over  two  enlarged  glands,  like  strings 
of  a  violin  over  its  bridge,  so  that  violent  pain  and  con- 
vulsive movements  were  set  up  in  the  limb. 

The  efferent  vessels  from  the  inguinal  glands  pass 
through  a  chain  of  lymphatic  glands  stretching  along 
the  course  of  the  external  and  common  iliac  vessels. 
Three  of  these  glands  lie  immediately  above  Poupart's 
ligament.  The  efferent  vessels  of  the  internal  iliac 
group  of  glands  into  which  the  pelvic  lymphatics  drain, 
join  the  chain  along  the  common  iliac  vessels.  The 
lumbar  glands  are  continuous  with  these. 

Elephantiasis  Arabum  is  more  common  in  the  lower 
limb  than  in  any  other  part,  and  leads  to  an  enormous 
increase  in  the  size  of  the  extremity  (Cochin  or  Bar- 
badoes  leg).  Its  pathology  is  intimately  concerned 
with  the  crural  lymphatics.  The  lymphatics  are  ob- 
structed by  a  small  thread  worm,  filaria  sanguinis 
hominis.     The  lymph  vessels  and  lymph  spaces  in  the 


43 8  Surgical  Applied  Anatomy.  [Chap.  xix. 

connective    tissue    become    greatly   distended,  and  the 
elements  of  the  connective  tissue  hypertrophied. 

The  hip  joint. — The  hip  joint  is  an  articulation 
of  considerable  strength  (Fig.  59,  p.  455).  This  strength 
depends  not  only  upon  the  shape  of  the  articulating 
bones,  which  permits  of  a  good  ball  and  socket  joint 
being  formed,  but  also  upon  the  powerful  ligaments 
that  connect  them  and  the  muscular  bands  that  directly 
support  the  capsule.  These  advantages,  however,  are 
to  some  extent  counterbalanced  by  the  immense  leverage 
that  can  be  brought  to  bear  upon  the  femur,  and  the 
numerous  strains  and  injuries  to  which  the  joint  is 
subjected,  as  the  sole  connecting  link  between  the  trunk 
and  the  lower  limb. 

The  acetabulum  is  divided  into  an  articular  and  a 
non-articular  part.  The  former  is  of  horse-shoe  shape, 
and  varies  from  1  inch  to  \  an  inch  in  width.  The 
bone  immediately  above  the  articular  area  is  very  dense, 
and  through  it  is  transmitted  the  superincumbent 
weight  of  the  trunk.  The  non-articular  part  corresponds 
to  the  area  enclosed  by  the  horse-shoe,  and  is  made  up 
of  very  thin  bone.  In  spite  of  its  thinness  it  is  very  rarely 
fractured  by  any  violence  that  may  drive  the  femur 
up  against  the  pelvic  bones,  since  no  ordinary  force  can 
bring  the  head  of  the  thigh-bone  in  contact  with  this 
segment  of  the  os  innominatum. 

Pelvic  abscesses  sometimes  make  their  way  into 
the  hip  joint  through  the  non-articular  part  of  the 
acetabulum,  and  an  abscess  in  the  hip  joint  may  reach 
the  pelvis  by  the  same  route.  But  both  such  circum- 
stances are  rare.  In  some  cases  of  destructive  hip 
disease  the  acetabulum  may  separate  into  its  three 
component  parts.  Up  to  the  age  of  puberty  these 
three  bones  are  separated  by  the  Y-shaped  cartilage. 
At  puberty  the  cartilage  begins  to  ossify,  and  by  the 
eighteenth  year  the  acetabulum  is  one  continuous  mass 
of  bone.  The  breaking  up  of  the  acetabulum  by  disease, 
therefore,  is  only  possible  before  that  year. 

The  manner  in  which  the  various  movements  at 
the  hip  are  limited  may  be  briefly  expressed  as  follows. 


chap,  xix.]       The  Region  of  the  Hip.  439 

Flexion,  when  the  knee  is  bent,  is  limited  by  the  contact 
of  the  soft  parts  of  the  groin,  and  by  some  part  of  the 
ischio-femoral  ligament  ;  when  the  knee  is  extended 
the  movement  is  limited  by  the  hamstring  muscles. 
Extension  is  limited  by  the  ilio-femoral  or  Y-ligament. 
Abduction  by  the  pubo-femoral  ligament.  Adduction 
of  the  flexed  limb  is  limited  by  the  ligamentum  teres 
and  ischio-femoral  ligament,  and  of  the  extended  limb 
by  the  outer  fibres  of  the  ilio-femoral  ligament  and 
upper  part  of  the  capsule.  Rotation  outwards  is  resisted 
by  the  ilio-femoral  ligament,  and  especially  by  its  inner 
part,  during  extension,  and  by  the  outer  limb  of  that 
ligament  and  the  ligamentum  teres  during  flexion. 
Rotation  inwards  is  limited  during  extension  by  the 
ilio-femoral  ligament,  and  during  flexion  by  the  ischio- 
femoral ligament  and  inner  part  of  the  capsule. 

Hip  joint  disease. — Owing  to  its  deep  position 
and  its  thick  covering  of  soft  parts,  this  articulation  is 
able  to  escape,  to  a  great  extent,  those  severer  injuries 
that  are  capable  of  producing  acute  inflammation  in 
other  joints.  Acute  synovitis  is  indeed  quite  rare  in  the 
hip,  and  the  ordinary  disease  of  the  part  is  of  a  distinctly 
chronic  character.  It  follows  also,  from  the  deep  position 
of  the  articulation,  that  pus,  when  it  is  formed  in  con- 
nection with  disease,  remains  pent  up,  and  is  long  before 
it  reaches  the  surface.  Suppuration  in  this  region, 
therefore,  is  often  very  destructive.  When  effusion 
takes  place  into  the  joint,  the  swelling  incident  thereto 
will  first  show  itself  in  those  parts  where  the  hip  capsule 
is  the  most  thin.  The  thinnest  parts  of  the  capsule 
are  in  front  and  behind  ;  in  front,  in  the  triangular 
interval  between  the  inner  edge  of  the  Y  ligament  and 
the  pectineo-femoral  ligament,  and  behind  at  the  pos- 
terior and  lower  part  of  the  capsule.  It  is  over  these 
two  districts  that  the  swelling  first  declares  itself  in 
cases  of  effusion  into  the  joint,  and  as  these  parts  are 
readily  accessible  to  pressure,  it  follows  that  they  cor- 
respond also  to  the  regions  where  tenderness  is  most 
marked  and  is  earliest  detected. 

In  chronic  hip  disease,   certain   false  positions  are 


440  Surgical  Applied  Anatomy.   [chap,  xix. 

assumed  by  the  affected  limb,  the  meaning  of  which 
it  is  important  to  appreciate.  These  positions  may 
be  arranged  as  follows,  according,  as  nearly  as  possible, 
to  their  order  of  appearing. 

(1)  The  thigh  is  flexed,  abducted,  and  a  little  everted  ; 
and  associated  with  this  there  is  (2)  apparent  lengthening 
of  the  limb  and  (3)  lordosis  of  the  spine  ;  (4)  the  thigh 
is  adducted  and  inverted,  and  incident  to  this  there  is 
(5)  apparent  shortening  of  the  limb  ;  (6)  there  is  real 
shortening  of  the  limb. 

1.  The  first  position  is  simply  the  posture  of 
greatest  ease.  It  depends  mainly  upon  the  effusion 
into  the  joint.  If  fluid  be  forcibly  injected  into  a  hip- 
joint  the  thigh  becomes  flexed,  abducted,  and  a  little 
everted.  In  other  words,  the  articulation  holds  the 
most  fluid  when  the  limb  is  in  this  position,  and  the 
patient  places  it  there  to  relieve  pain  by  reducing  the 
tension  within  the  capsule  to  a  minimum.  Flexion 
is  the  most  marked  feature  in  this  position.  Its  effect 
is  pronounced.  It  relaxes  the  main  part  of  the  Y  liga- 
ment, which,  when  the  limb  is  straight,  is  drawn  as  an 
unyielding  band  across  the  front  of  the  joint.  Abduction 
relaxes  the  outer  limb  of  this  ligament  and  the  upper 
part  of  the  capsule.  Eversion  slightly  relaxes  the  inner 
limb  of  the  Y  ligament  and  the  ischio-femoral  ligament. 
The  latter  movement  is  the  least  marked,  since  eversion, 
even  in  the  flexed  position  of  the  joint,  is  resisted  by 
the  outer  part  of  the  Y  ligament.  Any  but  a  moderate 
degree  of  abduction  would  be  limited  by  the  pubo- 
femoral ligament,  especially  as  that  band  is  rendered 
most  tense  when  abduction  is  combined  with  flexion 
and  rotation  outwards.  The  attachments  of  the  psoas 
muscle  are  approximated  and  its  pressure  over  the  joint 
relaxed. 

2.  The  apparent  lengthening  is  due  to  the  tilting 
down  of  the  pelvis  on  the  diseased  side,  and  is  the  result 
of  the  patient's  attempts  to  overcome  the  effects  of 
the  position  just  described.  The  limb  is  shortened 
by  flexion  and  abduction,  and  to  bring  the  foot  again 
to  the  ground  and  to  restore  the  natural  parallelism  of 


chap,  xix.]       The  Region  oe  the  Hip. 


441 


the  limbs,  the  pelvis  has  to  be  tilted  down  on  the  affected 
side.  Thus,  an  apparent  lengthening  is  produced, 
which  is  seen  when  the  patient  lies  upon  a  bed  and  the 
abduction  is  made  to  disappear.  Real  lengthening  of 
the  limb  can  scarcely  be  produced  by  the  effusion  into 
the  joint.  By  forcible  injection  into  the  joint  Braune 
could  only  separate  the 
articulating  surfaces 
about  |th  of  an  inch. 

3.  The  lordosis,  or 
curving  forwards,  of 
the  spine  occurs  in 
the  dorso-lumbar 
region.  It  depends 
upon  the  flexion  of  the 
limb,  and  is  the  result 
of  an  attempt  to  con- 
ceal that  false  position, 
or  at  least  to  minimise 
its  inconveniences  (Fig. 
54).  When  the  thigh 
is  flexed  at  the  hip  by 
disease,  the  lower  limb 
can  be  made  to  appear 
straight  by  simply 
bending  the  spine  for- 
wards   in    the    dorso- 

1  1  •  -j. i,        t.  a   Femur  flexed  at  hip.  pelvis  (represented  1>> 

lumbar  region  Without  A'  *ffi !   dotted    line)    straight,    and    spine 
pffpptino-         tViP         lpiqf  normal,      b,    Tue    flexion     concealed    or 

eneciing        Hie        least  overepme  by  lordosis  of  the  spine;    the 

movement   at   the   dis-  pelvis  rendered  oblique. 

ordered  joint.    Indeed, 

the  movement  proper  to  the  hip  is  in  this  case  transferred 
to  the  spine.  A  patient  with  a  flexed  hip  as  the  result  of 
disease  can  lie  on  his  back  in  bed,  with  both  limbs  ap- 
parently perfectly  straight,  he  having  concealed  the 
flexion,  as  it  were,  by  producing  a  lordosis  of  the  spine.  If 
the  lordosis  be  corrected,  and  the  spine  be  made  straight 
again,  then  the  flexion  of  the  hip  reappears,  although 
all  the  time  the  hip-joint  has  been  absolutely  rigid. 
This  lordosis  generally  appears  a  little  late  in  the  disease, 


L 

B 


54.—  Diagram  to  show  the  Mode  of 
Production  of  Lordosis  in  Hip  Disease. 


Fig 


442  Surgical  Applied  Anatomy.   [Chap.  xix. 

and  after  the  limb  has  become  more  or  less  fixed  in 
the  false  positions  by  contraction  of  the  surrounding 
muscles. 

4.  Sooner    or    later,    in    hip    disease,    the    thigh 
becomes  adducted  and  inverted,  while  it  still  remains 
flexed.     The  head  of  the  femur  then  rests  on  the  upper 
and  posterior  part  of   the  acetabulum,  quite  half  of  it 
being    outside    the    socket.      This    position    has    been 
variously    accounted    for.     According   to    one    theory, 
it  is  due  to  softening  and  yielding  of  some  parts  of  the 
inflamed  capsule.     This  view  is  set  forth  by  Mr.  Barker, 
in  his  admirable  monograph  on  joint  disease  in  Holmes' 
"  System  of  Surgery,"  in  the  following  words :    "  As 
the  inflamed  capsule  commences  to  soften,  its  weakest 
part  yields  first,  i.e.  the  posterior  inferior.      This  now 
admits  of  more  flexion  still.     .     .     .     The  horizontal 
posterior  fibres,  which  in  the  distended  condition  of 
the  capsule  help  in  the  e version,  are  the  next  to  stretch, 
admitting  of  inversion,  which  is  now  the  more  possible 
as  the  Y  is  relaxed  by  flexion,  and  its  inner  limb  has 
no  strain  to  be  taken  off  by  eversion.     Finally,   the 
upper  and  outer  anterior  fibres  yield,  and  adduction 
then  takes  place."     This  explanation  is  a  little  unsatis- 
factory ;  and  it  is  more  probable  that  this  false  position, 
and  especially  the  adduction,  depends  upon  muscular 
action.    The  muscles  about  the  joint  are  in  a  state 
of  irritability.     They  are  contracted  by  a  reflex  action 
that  starts  from  the  inflamed  articulation,  and  since 
the  adductor  muscles  are  supplied  almost  solely  by  the 
obturator  nerve,  it  is  not  unreasonable  to  expect  them 
to  be  especially  disturbed  if  the   large  share  that  the 
obturator  nerve  takes   in   the   supply  of   the   hip   be 
borne    in    mind.      The    adductors    are    also    rotators 
outwards,  but  this  latter  movement  would  be  resisted 
by  the  strong  outer  limb  of  the  Y  ligament,  as  well  as 
by  the  ligamentum  teres,  both  of  which  are  rendered 
tense  by  rotation  outwards  during  flexion.     The  whole 
matter,  however,  requires  further  investigation. 

5.  Apparent  shortening  of  the  limb  is  due  to  tilting 
up  of  the  pelvis  on  the  diseased  side,  and  bears  the  same 


Chap,  xix.]       The  Region  of  the  Hit. 


443 


relation  to  adduction  that  apparent  lengthening  bears 
to  abduction.  To  overcome  the  adduction,  and  to 
restore  the  natural  parallelism  of  the  limbs,  the  patient 
tilts  up  one  side  of  his  pelvis  (Fig  55).     It  thus  happens 


a- 


\ 


*l      B 


C  d 

fig     5p4 — a,  Parts  in  Normal  Position,     b,  Femur  adducted.    c,  The 
Adduction  corrected  by  tilting  up  the  Pelvis. 

ac,  I.mc  of  pelvis;  oh,  limb  on  diseased  side;  cd,  limb  on  sound  side;  e,  the 
suine.  It  will  be  found  that  in  Pigs.  B  and  c  the  angle  at  a  is  the  samein 
the  two  eases. 

that  a  patient  with  his  femur  flexed  and  adducted  by 
disease  may  lie  in  bed  with  both  limbs  quite  straight 
and  parallel,  but  with  one  limb  obviously  shorter  than 
the  other.  The  flexion  in  such  a  case  is  concealed  by 
lordosis,  and  the  adduction  by  the  tilting  of  the  pelvis. 


444  Surgical  Applied  Anatomy.   [Chap.  xix. 

In  some  cases  of  simultaneous  disease  in  both  hip-joints 
that  has  been  indifferently  treated,  both  thighs  may 
remain  adducted.  The  limbs  are  unable,  of  course, 
to  remedy  their  position  by  the  usual  means,  when 
the  disease  is  double,  and  consequently  one  limb  is 
crossed  in  front  of  the  other,  and  the  peculiar  mode 
of  progression  known  as  "  cross-legged  progression " 
is  produced. 

6.  The  real  shortening  depends  upon  destructive 
changes  in  the  head  of  the  bone,  or  upon  dislocation  of 
the  partly  disintegrated  head  on  to  the  dorsum  ilii, 
through  yielding  of  the  softened  capsule  and  the 
crumbling  away  of  the  upper  and  posterior  margin  of 
the  acetabulum. 

When  hip  disease  commences  in  bone  it  usually 
involves  the  epiphyseal  line  that  unites  the  head  of 
the  femur  to  the  neck.  This  line  is  wholly  within  the 
joint,  and  the  epiphysis  that  forms  the  head  unites 
with  the  rest  of  the  bone  about  the  eighteenth  or 
nineteenth  year. 

When  the  bone  is  primarily  involved  the  position 
of  flexion  and  abduction  with  eversion  may  not  be 
observed  at  all,  there  being  no  effusion  at  first  into  the 
joint.  In  such  cases  the  limb  becomes  at  once  flexed 
and  adducted,  and  this  posture  is  probably  due  solely 
to  muscular  spasm,  and  to  an  attempt  to  prevent  the 
head  of  the  femur  from  pressing  against  the  acetabulum, 
and  so  causing  pain. 

It  is  well  known  that  patients  with  hip  disease  often 
complain  of  pain  in  the  knee.  This  referred  pain  may 
be  so  marked  as  to  entirely  withdraw  attention  from 
the  true  seat  of  disease.  Thus  I  once  had  a  child  sent 
to  the  hospital  with  a  sound  knee  carefully  secured  in 
splints,  but  without  any  appliance  to  the  hip,  which  was 
the  seat  of  a  somewhat  active  inflammation.  This 
referred  pain  is  easy  to  understand,  since  the  two  joints 
are  supplied  from  the  same  segments  of  the  spinal  cord. 
In  the  hip,  branches  from  (1)  the  anterior  crural  enter 
at  the  front  of  the  capsule  ;  (2)  branches  from  the 
obturator  at  the  lower  and  inner  part  of  the  capsule  ; 


Chap,  xix]       The  Region  oe  the  Hip.  445 

and  (3)  brandies  from  the  sacral  plexus  and  sciatic 
nerve  at  the  posterior  part  of  the  joint.  In  the  knee, 
branches  from  (1)  the  anterior  crural  (nerves  to  vasti) 
enter  at  the  front  of  the  capsule  ;  (2)  branches  from 
the  obturator  at  the  posterior  part  of  the  capsule  ;  and 
(3)  branches  from  the  internal  and  external  popliteal 
divisions  of  the  great  sciatic  nerve  at  the  lateral  and 
hinder  aspects  of  the  joint. 

Pain,  therefore,  in  the  front  of  the  knee,  on  one 
or  both  sides  of  the  patella,  has  probably  been  referred 
along  the  anterior  crural  curve,  and  pain  at  the  back 
of  the  joint  along  the  obturator  or  sciatic  nerves. 

In  hysterical  individuals  joint  disease  may  be  imi- 
tated by  certain  local  nervous  phenomena,  the  articula- 
tion itself  being  quite  free  from  structural  change.     This 
affection  most  commonly  shows  itself  in  the  hip  or  knee, 
and  the  "  hysterical  hip,"  or  "  hysterical  knee,"  takes  a 
prominent  place  in   the  symptomatology  of  hysteria. 
It  is  not  quite  easy  to  understand  why  these  two  large 
joints  should  be  so  frequently  selected  for  the  mimicry 
of  disease.     Hilton  has  endeavoured  to  explain  the  fact 
upon  anatomical  grounds,  having  reference  to  the  nerve 
supply  of  these  joints  in  relation  to  the  nerve  supply 
of    the    uterus.       The  uterus  is  mainly    supplied    by 
an  offshoot  from  the  hypogastric  plexus,  and  by  the 
third  and  fourth  sacral  nerves.     Now,  the  hypogastric 
plexus  contains  filaments  derived  from  the  lower  lumbar 
nerves  ;   and  from  the  same  trunks  two  nerves  to  the 
hip  and  knee   (the  anterior  crural  and  obturator)   are 
in  great  part  derived.     The  great  sciatic  also  contains 
a  large  portion  of  the  third  sacral  nerve.     The  common 
origin  of    the  joint    and    uterine    nerves    forms    the 
basis  of  Hilton's  explanation  of  the  relative  frequency 
of  hysterical  disease  in  the  large  articulations  of  the 
lower  limb.     The  explanation,  however,  is  unsatisfactory, 
since  the  uterus  receives  many  of  its  nerves  from  the 
ovarian  plexus,  and  the  theory  is  founded  upon  the 
unwarranted  supposition  that  all  hysterical  disorders 
are  associated  with  some  affection  of  the  uterus  or  its 
appendages.  __  More  recently  Head  has  revived  a  modified 


446  Surgical  Applied  Anatomy.   [Chap.  xix. 

form  of  Hilton's  theory.  He  explains  the  connection 
not  through  an  anatomical  association  of  nerves,  but 
through  an  association  of  the  centres  from  which  nerves 
arise  in  the  spinal  cord.  The  spinal  segments  from  which 
the  obturator  nerve  arises,  the  second,  third,  and  fourth, 
contain  no  visceral  nerves,  and,  therefore,  cannot  be 
associated  with  visceral  conditions.  On  the  other  hand, 
the  sacral  segments  from  which  the  great  sciatic  nerve 
arises  are  those  which  supply  the  pelvic  viscera. 

Fractures  of  the  upper  end  of  the  femur 
may  be  divided  into  (l)  fractures  of  the  neck  wholly 
within  the  capsule  ;  (2)  fractures  of  the  base  of  the  neck 
not  wholly  within  the  capsule  ;  (3)  fractures  of  the  base 
of  the  neck  involving  the  great  trochanter  ;  (4)  separa- 
tions of  epiphyses.  It  can  be  scarcely  possible,  apart 
from  gunshot  injuries,  to  fracture  the  neck  of  the  femur 
by  direct  violence,  owing  to  the  depth  at  which  the  bone 
is  placed,  and  the  manner  in  which  it  is  protected  by  the 
surrounding  muscles.  The  violence,  therefore,  that 
causes  the  lesion  is  nearly  always  supplied  indirectly  to 
the  bone,  as  by  a  fall  upon  the  feet  or  great  trochanter, 
or  by  a  sudden  wrench  of  the  lower  limb. 

M.  Kodet,  by  a  series  of  experiments,  concludes 
that  the  situation  of  the  fracture  can  be  predicated 
by  a  knowledge  of  the  direction  in  which  the  violence 
has  acted.  "  Thus,  a  force  acting  vertically,  as  in  falling 
on  the  feet  or  knees,  will  produce  an  oblique  intra- 
capsular fracture  ;  a  force  acting  from  before  backwards, 
a  transverse  intracapsular  fracture  ;  one  from  behind 
forwards,  a  fracture  partly  within  and  partly  without 
the  capsule ;  and  a  force  applied  transversely,  a  fracture 
entirely  without  the  capsule."  (Quoted  by  Henry 
Morris  ;   Holmes'  "  System  of  Surgery.") 

1.  The  true  intracapsular  fracture  may  involve 
any  part  of  the  cervix  within  the  joint,  but  is  most 
usually  found  near  the  line  of  junction  of  the  head 
with  the  neck.  This  fracture  is  most  common  in  the 
old,  in  whom  it  may  be  produced  by  very  slight  degrees 
of  violence.  The  liability  of  the  aged  to  this  lesion 
js  explained  upon  the  following  grounds.     The  angle 


chap,  xix.]       The  Region  of  the  Hip.  447 

between  the  neck  and  shaft  of  the  femur,  which  will 
be  about  130°  in  a  child,  tends  to  diminish  as  age  ad- 
vances, so  that  in  the  old  it  is  commonly  about  125°. 
In  certain  aged  subjects,  as  a  result  probably  of  gross 
degenerative  changes,  this  angle  may  be  reduced  to  a 
right  angle.  This  diminution  of  the  angle  certainly 
increases  the  risk  of  fracture  of  the  neck  of  the  bone. 
There  is  often,  also,  in  advanced  life,  much  fatty  degenera- 
tion of  the  cancellous  tissue  of  the  cervix  with  thinning 
of  the  compact  layer.  Dr.  Merkel  (Amer.  Journ.  Med. 
Sc,  1874)  also  asserts  that  in  old  persons  there  is  an 
absorption  of  that  process  of  the  cortical  substance 
which  runs  on  the  anterior  part  of  the  neck  between 
the  lesser  trochanter  and  the  under  part  of  the  head. 
This  process  he  calls  the  "  calcar  femorale,"  and  main- 
tains that  it  occupies  the  situation  at  which  the  greatest 
pressure  falls  when  the  body  is  erect.  These  fractures 
are  but  rarely  impacted  ;  but  when  impacted,  the  lower 
fragment,  represented  by  the  relatively  small  and  com- 
pact neck,  is  driven  into  the  larger  and  more  cancellous 
fragment  made  up  of  the  head  of  the  bone.  The  frac- 
ture may  be  subperiosteal,  or  the  fragments  may  be 
held  together  by  the  reflected  portion  of  the  capsule. 
These  reflected  fibres  pass  along  the  neck  of  the  bone 
from  the  attachment  of  the  capsule  at  the  femur  to  a 
point  on  the  cervix  much  nearer  to  the  head.  "  These 
reflected  fibres  occur  at  three  places,  one  corresponding 
in  position  to  the  middle  of  the  ilio-femoral  ligament, 
another  to  the  pectineo-femoral,  and  the  third  on  the 
upper  and  back  part  of  the  neck "  (Henry  Morris). 
Fractures  of  this  part  very  rarely  indeed  unite  by  bone. 
Blood  is  brought  to  the  head  of  the  bone  by  the  cervix, 
the  reflected  parts  of  the  capsule,  and  the  ligamentum 
teres.  When  the  first  two  sources  of  blood  supply 
are  cut  off  by  the  fracture  the  third  does  not  appear  to  be 
sufficient  to  allow  of  great  reparative  changes  taking 
place  in  the  upper  fragment.  The  fractures  that  heal 
by  bone  are  probably  either  impacted,  or  subperiosteal, 
or  not  wholly  intracapsular. 

2,  With  regard   to  fractures   at    the   base   of   the 


448  Surgical  Applied  Anatomy.   [Chap.  xix. 

neck,  it  must  be  remembered  that  a  wholly  extracapsular 
fracture  of  the  neck  of  the  femur  is  an  anatomical  im- 
possibility. If  the  fracture  is  wholly  without  the  capsule, 
then  it  must  involve  a  part  of  the  femoral  shaft,  and 
cannot  be  entirely  through  the  cervix.  In  the  front  of 
the  bone  the  capsule  is  attached  to  the  femur  along 
a  part  of  the  inter-trochanteric  line,  and  strictly  follows 
the  line  of  junction  between  the  cervix  and  the  shaft. 
Behind,  the  capsule  is  inserted  into  the  neck  about  \  an 
inch  in  front  of  the  posterior  inter-trochanteric  line. 
It  is  therefore  possible  for  a  fracture  of  the  neck  to  be 
extracapsular  behind,  but  not  in  front,  and  many  of  these 
lesions  at  the  base  of  the  neck  have  this  relation  to  the 
capsule.  The  Y  ligament  is  so  thick,  being  in  one  place 
about  \  of  an  inch  in  thickness,  that  a  fracture  involv- 
ing the  base  of  the  cervix  may  run  between  its  fibres 
at  their  attachment,  and  be  neither  extra  nor  intra- 
capsular. When  fractures  at  the  junction  of  the  neck 
and  shaft  are  impacted,  the  upper  fragment,  represented 
by  the  compact  and  relatively  small  cervix,  is  driven  into 
the  cancellous  tissue  about  the  great  trochanter  and  upper 
end  of  the  shaft.  As  a  result  of  this  impaction  the 
trochanter  may  be  split  up,  and  the  bones  may  become 
free  again  through  the  extent  of  this  splintering. 

With  regard  to  the  symptoms  of  a  fracture 
of  the  neck  of  the  femur,  the  following  may  be 
noticed  :  (a)  The  swelling  often  observed  in  the  front 
of  the  limb,  just  below  Poupart's  ligament,  is  due  either 
to  effusion  of  blood  into  the  joint  or  to  projection  of 
the  fragments  against  the  front  of  the  capsule  ;  (6) 
the  shortening  is  brought  about  by  the  glutei,  the 
hamstrings,  the  tensor  vaginae  femoris,  the  rectus, 
sartorius,  and  ilio-psoas,  the  adductors,  gracilis  and 
pectineus  ;  (c)  the  eversion,  or  rotation  outwards  of 
the  limb,  is  mainly  due  to  two  causes  :  (1)  The  weight 
of  the  limb,  which  causes  it  to  roll  outwards,  as  is  seen 
in  persons  insensible  or  asleep,  the  line  of  gravity  passing 
through  the  outer  part  of  the  thigh  ;  (2)  the  fact  that 
the  compact  tissue  on  the  posterior  aspect  of  the  neck 
is  much  more  fragile  than  that  on  the  anterior  aspect. 


chap.  xix.  j       The  Region  of  the  Hi  p.  449 

Thus  the  cervix  is  often  more  extensively  fractured 
behind  than  in  front,  or  the  fracture  may  be  impacted 
behind  but  not  in  front,  and  in  either  case  the  limb 
will  tend  to  become  everted.  As  a  third  cause  may 
be  mentioned  the  action  of  the  ilio-psoas,  the  adductor 
and  pectineus  muscles,  and  of  the  small  rotator  muscles, 
all  of  which  will  tend  to  roll  the  femur  outwards. 

3.  Fracture  of  the  base  of  the  neck,  involving  the 
great  trochanter.  In  this  lesion  the  head,  the  cervix, 
and  a  part  of  the  great  trochanter  arc  separated  from 
the  shaft  and  rest  of  the  trochanter. 

4.  Separation  of  epiphyses.  There  are  three 
epiphyses  in  the  upper  end  of  the  femur  :  one  for  the 
head,  which  unites  between  eighteen  and  nineteen  ; 
one  for  the  lesser  trochanter,  which  unites  about 
seventeen  ;  and  one  for  the  greater  trochanter,  which 
unites  about  eighteen.  The  neck  is  formed  by  an 
extension  of  ossification  from  the  shaft.  A  few  cases 
are  recorded  where  it  is  supposed  that  the  caput  femoris 
was  separated  at  the  epiphyseal  line  by  violence,  but 
the  accident  is,  I  believe,  illustrated  by  no  actual  speci- 
mens. Mr.  Henry  Morris  has  collected  five  cases  of 
separation  of  the  epiphysis  of  the  great  trochanter. 
This  separation,  if  complete,  could  hardly  avoid  being 
intracapsular  in  part,  since  the  capsule  is  attached 
to  the  anterior  superior  angle  of  the  trochanter  itself. 

In  the  condition  known  as  coxa  vara  the  neck  of 
the  femur  sinks  under  the  weight  of  the  body,  coming 
to  form  an  angle  of  90°  or  less  with  the  shaft  of  the 
femur.  It  occurs  in  adolescents.  Owing  to  the 
prominence  of  the  trochanter  and  shortening  of  the 
limb  which  necessarily  result,  the  condition  may  be 
mistaken  for  a  fracture  of  the  neck  of  the  femur  or  a 
congenital  dislocation  of  the  hip-joint. 

Dislocations  ol  the  hip. — These  injuries  are 
comparatively  rare,  on  account  of  the  great  strength 
of  the  articulation,  and  when  they  occur  in  a  healthy 
joint  are  always  the  result  of  a  considerable  degree  of 
violence.  A  dislocation  of  the  hip  may  be  congenital, 
or  may  be  spontaneously  produced  by  muscular  efforts, 

2D 


4  5°  Surgical  Applied  Anatomy.   [Chap.  xix. 

as  shown  in  a  few  rare  cases,  or  may  be  the  result  of 
disease  of  the  articulation.  Congenital  dislocation  of 
the  hip  joint  is  due  in  most  instances  to  a  failure  in 
the  development  of  the  acetabulum.  In  such  cases 
the  acetabulum  retains  the  shallow  character  seen 
during  the  second  month  of  foetal  life.  The  outgrowth 
of  the  acetabular  rim  fails,  especially  the  iliac  part.  The 
head  of  the  femur  is  flat  and  the  neck  short,  and  the 
bone  slips  backwards  on  the  dorsum  ilii  when  the  child 
learns  to  walk.  The  weight  of  the  body  is  supported 
by  the  muscles  and  ligaments  round  the  hip- joint. 
If  replaced  the  head  again  slips  from  the  shallow  cavity. 
In  time  osteophytic  outgrowths  from  the  ilium  lead 
to  the  formation  of  a  new  cavity. 

In  dislocations  due  to  violence  the  head  of  the  bone 
may  be  found  displaced  in  four  directions,  producing 
the  four  regular  dislocations  of  the  hip.  In  two  the 
head  of  the  femur  is  posterior  to  a  line  drawn  vertic- 
ally through  the  acetabulum,  and  in  the  other  two 
it  is  found  anterior  to  that  line. 

(1)  Backwards  and  upwards.  Head  rests  upon 
ilium,  just  above  and  behind  acetabulum.  The  "  dis- 
location upon  the  dorsum  ilii."  (2)  Backwards.  Head 
rests  upon  ischium,  and,  as  a  rule,  about  on  a  level 
with  the  ischial  spine.  The  "  dislocation  into  the  sciatic 
notch."  (3)  Forwards  and  downwards.  Head  rests  on 
thyroid  foramen.  The  "obturator  or  thyroid  dislocation." 
(4)  Forwards  and  upwards.  Head  rests  upon  the  body 
of  the  pubes,  close  to  its  junction  with  the  ileum.  The 
"  dislocation  upon  the  pubes." 

The  above  arrangement  represents  also  the  order 
of  frequency  of  these  luxations,  No.  1  being  the  most 
common  dislocation  of  this  part,  and  No.  4  the  most  rare. 

General  facts. — In  all  these  dislocations  of  the 
hip,  (a)  the  luxation  occurs  when  the  limb  is  in  the 
position  of  abduction  ;  (b)  the  rent  in  the  capsule  is 
always  at  its  posterior  and  lower  part ;  (c)  the  head 
of  the  bone  always  passes  at  first  more  or  less  directly 
downwards  ;  (d)  t  he  Y  ligament  is  untorn,  while  the 
iigamentum  teres  is  ruptured. 


chap,  xix.]       The  Region  of  the  Hip.  45 1 

(a)  It  is  maintained  that  in  all  luxations  at  the  hip, 
the  pelvis  and  femur  are  in  the  mutual  position  of 
abduction  of  the  latter  at  the  time  of  the  accident.  The 
direction  of  the  neck  of  the  femur  and  of  the  acetabulum, 
and  the  position  of  the  cotyloid  notch,  all  favour  dis- 
location in  the  abducted  posture.  The  lower  and  inner 
part  of  the  acetabulum  is  very  shallow,  and  the  lower 
and  posterior  part  of  the  capsule  is  very  thin.  In 
abduction,  the  head  of  the  bone  is  brought  to  the  shallow 
part  of  the  acetabulum  ;  it  moves  more  than  half  out 
of  that  cavity  ;  it  is  supported  only  by  the  thin  weak 
part  of  the  capsule,  and  its  further  movement  in  the 
direction  of  abduction  is  limited  only  by  the  pectineo- 
femoral  ligament,  a  somewhat  feeble  band.  In  abduc- 
tion the  round  ligament  is  slack,  and  in  abduction 
with  flexion  both  the  Y  ligament  and  the  ischio-femoral 
ligaments  are  also  relaxed.  In  the  position  of  abduction, 
therefore,  no  great  degree  of  force  may  be  required 
to  thrust  the  head  of  the  bone  through  the  lower  and 
posterior  part  of  the  capsule  and  displace  it  downwards. 

(6)  The  above  being  allowed,  it  will  be  understood 
that  the  rent  in  the  capsule  is  always  at  its  posterior 
and  lower  parts.  "  Generally  the  rupture  is  jagged 
and  irregular,  but  will  be  found  to  extend  more  or 
less  directly  from  near  the  shallow  rim  of  the  acetabulum, 
across  the  thin  portion  of  the  capsule  to  the  femur  near 
the  small  trochanter,  and  then  to  run  along  the  back 
of  the  ligament  close  to  its  attachment  to  the  neck  of 
the  bone  "  (Henry  Morris). 

(c)  If  the  position  of  the  limb  at  the  time  of  the 
accident  be  considered,  it  will  be  seen  that  the  femur 
will  in  every  case  be  displaced  downwards.  There  is, 
indeed,  but  one  primary  dislocation  of  the  hip — a  luxation 
downwards.  The  four  forms  given  above  are  all 
secondary,  the  bone  having  in  each  instance  first  passed 
downwards  before  it  moved  to  any  of  the  positions 
indicated.  This  point  has  been  ably  demonstrated 
by  Mr.  Henry  Morris,  whose  account  of  the  anatomy 
of  hip  dislocations  is  most  valuable.  The  head  having 
left  the  acetabulum,  its  ultimate  destination  will  depend 


45  2 


Surgical  Applied  Anatomy.   [Chap.xix. 


upon  the  character  of  the  dislocating  force.  "  If  the 
limb  be  flexed  on  the  pelvis,  and  rotated  inwards,  or 
the  pelvis  be  correspondingly  moved  on  the  thigh  at 
the  moment  of  displacement,  the  head  of  the  femur 
will  take  a  backward  course  and  rest  on  the  dorsum 
ilii  or  some  part  of  the  ischium.  On  the  other  hand, 
extension  and  outward  rotation  will  cause  the  head 
of  the  bone  to  travel  upwards  and  forwards,  and  what 

is  called  a  dislocation 
on  to  the  pubis  will 
occur.  ...  If  the 
dislocation  is  neither 
accompanied  nor  fol- 
lowed by  rotation  or 
fixed  flexion  or  ex- 
tension, the  head  of 
the  femur  will  remain 
below  the  acetabu- 
lum, and  will  occupy 
the  foramen  ovale  if 
it  takes  a  slightly  for- 
ward direction  in  its 
descent,  or  some 
position  near  the 
tuberosity  of  the 
ischium  if  it  leaves 
its  socket  in  a  back- 
ward and  downward 
direction  "  (Henry 
Morris). 
(d)  The  Y  ligament  is  never  torn  in  any  "  regular  " 
dislocation.  It  is  saved  by  its  great  density  and  the 
circumstance  that  it  is  probably  more  or  less  relaxed 
at  the  time  of  the  luxation.  The  method  of  reducing 
these  dislocations  by  manipulation  depends  for  its  success 
mainly  upon  the  integrity  of  the  Y  ligament,  which 
acts  as  the  fulcrum  to  a  lever  of  which  the  shaft  of  the 
femur  is  the  long  arm  and  the  neck  the  short.  In 
the  backward  luxations  the  head  is  behind  the  Y  liga- 
ment, and  in  the  forward  displacements  in  front  of  it. 


-Dislocation  upon  the  Dorsum  ilii 
(Bigelow). 


Chap,  xix.]       The  Region  of  '/he  Hip. 


453 


The  anatomy  of  cacli  form. — Nos.  1  and  2. 
The  dislocations  backwards.  Here  the  femoral  head, 
having  been  displaced  in  the  way  indicated,  is  carried 
towards  the  dorsum  or  sciatic  notch  by  the  glutei, 
hamstring,  and  adductor  muscles.  The  bone  having 
taken  a  general  direction  backwards,  the  height  to 
which  it  ascends  depends  mainly  upon  the  nature  of 
the  dislocating  force,  and  also  upon  the  extent  of  the 
rupture  in  the  capsule 
and  the  laceration  of 
the  obturator  interims 
tendon  and  other 
small  external  rota- 
tors. The  dorsal  dis- 
location is,  therefore, 
a  more  advanced 
grade  of  the  sciatic. 
The  more  extreme  the 
flexion  and  inward 
rotation  at  the  time 
of  the  accident,  the 
more  likely  is  the  dis- 
location to  be  sciatic. 
More  moderate  flexion 
and  inward  rotation 
will  produce  a  luxa- 
tion upon  the  dorsum. 
In  the  dorsal  luxation 
the  head  is  above  the  Fig. 
obturator  interims 
tendon,  while  in  the 

sciatic  form  it  is  below  it  (Bigelow).  Morris  has  been 
able  to  find  but  one  case  of  direct  dislocation  of  the 
femur  backwards  on  to  the  ischium.  In  every  instance 
it  passes  first  in  a  downward  direction,  and  then 
backwards. 

Bigelow  states  that  there  is  no  evidence  to  show 
that  the  head  of  the  femur  has  ever  been  actually 
displaced  into  the  sciatic  notch. 

In  these  backward  dislocations  the  ilio-psoas  muscle 


-Obturator  or  Thyroid  Disloca- 
tion (Bigelow), 


454 


Surgical  Applied  Anatomy.    [Chap.  xix. 


is  greatly  stretched.  The  quadratus  femoris,  the 
obturators,  the  gemelli,  and  the  pyriformis  are  more 
or  less  lacerated.  The  pectineus  is  often  torn,  and 
the  glutei  muscles  even  may  be  ruptured  in  part.  The 
great  sciatic  nerve  may  be  compressed  between  the 
femoral  neck  and  the  rotator  muscles,  or  between  the 
head  of  the  bone  and  the  tuber  ischii.     In  both  of  the 

backward  luxations  there 
is  shortening,  due  to  the 
circumstance     that     the 
Une  between  the  anterior 
superior   spine   and   the 
femoral  condyles   is   les- 
sened by  the  displacement 
backwards  of  the  bone, 
with       the      additional 
shortening  in  the  dorsal 
dislocation  brought  about 
by    the    passing   of   the 
femoral  head  above  the 
level  of  the  acetabulum. 
The   adduction   and   in- 
version    in     the      main 
depend  upon  the  position 
of  the  head  and  cervix, 
which    must    follow  the 
plane  of  the  bone  upon 
which    they    lie.      This 
position     is     maintained 
by  the  tense  Y  ligament. 
The  damage  done  to  the 
chief    external    rotators 
places  them  also  hors  de  combat.     The  flexion  is  due  to 
the  tension  of  the  Y  ligament  and  of  the  ilio-psoas  muscle. 
Nos.   3  and  4.     The  dislocation  fomvards.     If  the 
head  after  leaving  the  acetabulum  simply  moves  a  little 
forwards  along  the  inner  edge  of  the  socket,  the  thyroid 
luxation   is   produced.     If  it  goes  farther  and   moves 
upwards,  the  pubic  displacement  will  result.     The  latter 
dislocation  is  therefore  but  an  advanced  form  of  the 


Fig.  58.-Dislocation  upon  the  Pubes 
(Bigelow). 


Chap,  xi  x.j       The  Region  of  the  Hip. 


455 


first-named.  Whether  the  head  will  remain  in  the 
thyroid  foramen  or  ascend  on  to  the  pubes  depends 
on  whether  extension  and  rotation  outwards  accompanies 


Fig.  5.'.— Vertical  section  of  the  Upper  Third  of  the  Thigh  showing  the 
structures  in  relationship  with  the  hip-joint.    (Ajter  Braune.) 

Muscles.— 1,  psoas;  2,  iliacus;  3,  gluteus  niedius;  4,  gluteus  minimus;  5,  ob- 
turator internus;  6,  obturator  extcrnus ;  7,  iliopsoas;  8,  pectineus;  9,  ad- 
ductor maKnus  ;  10,  adductor  brevis;  LI,  gracilis;  12,  adductor  longus ; 
13,  vastus  internus;  l-l,  vastus externus;  a, anterior  crural  nerve;  b,  external 
iliac  artery  ;  c,  external  iliac  vein  ;  </,  obturator  nerve  ;  e,  obturator  artery  ; 
/branches  of  obturator  vessels  to  hip  joint ;  </,  internal  circumflex  vessels: 
ft,  deep  femoral  vessels;  /,  branch  of  external  circumflex:  j,  bursa  over 
great  trochanter ;  ic,  reflections  of  capsule  to  neck  of  femur ; m,  asc.  ramus 
of  pubes  ;  n,  peritoneum  ;  <\  iliac  fascia. 

the  displacement.  If  these  occur  the  pubic  form  is 
produced.  In  these  injuries  the  pectineus,  gracilis, 
and  adductors  will  be  more  or  less  torn,  while  the  ilio- 
psoas, glutei,  and  pyriform  muscles  are  much  stretched. 


456  Surgical  Applied  Anatomy.  [Chap.  xix. 

The  obturator  nerve  may  be  stretched  or  torn,  and  in 
the  pubic  luxation  the  anterior  crural  nerve  may  be 
involved.  The  abduction  and  eversion  of  the  limb 
noticed  in  these  luxations  depend  partly  upon  the  position 
of  the  head  of  the  bone,  fixed  more  or  less  by  the  Y 
ligament,  and  partly  upon  the  action  of  the  gluteal 
muscles  and  some  of  the  small  external  rotators,  which 
are  tightly  stretched.  The  flexion  of  the  limb  is  mainly 
due  to  the  stretching  of  the  ilio-psoas  muscle. 

In  the  thyroid  luxation  the  extremity  is  said  to  be 
lengthened.  This  lengthening  is,  however,  apparent, 
and  is  due  to  the  tilting  down  of  the  pelvis  on  the  injured 
side.  In  the  pubic  dislocation  there  is  shortening,  the 
head  being  carried  above  the  acetabular  level. 

Of  the  modes  of  reducing  these  dislocations  by 
manipulation  little  can  be  said  here.  The  more  usual 
proceedings  may  be  briefly  summarised  as  follows  : 

First. — Flex  the  thigh  in  the  adducted 
position  in  luxations  Nos.  1 
and  2.  i      To  relax  the 

Flex  the  thigh  in  the  abducted  ,      Y  ligament, 
position  in  luxations  Nos.  3 
and  4.  / 

Secondly. — Circumduct  out  in\    To  bring  back  the  head 
Nos.  1  and  2. !      to  the  rent  in  the  cap- 
Circumduct  in  in  I      sule  by  the  same  route 
Nos.  3  and  4  J      that  it  has  escaped. 
Thirdly. — Extend  in  all  cases.       To  induce  the  head 
to  again  enter  the  acetabulum. 

In  reducing  dislocations  of  the  hip  it  may  be  noted 
that  the  internal  condyle  of  the  femur  faces  in  nearly 
the  same  direction  as  the  head  of  the  bone. 

In  amputation  of  the  thigh  at  the  hip- 
joint  many  methods  may  be  employed.  A  common 
procedure  consists  of  a  circular  incision  which  divides 
the  soft  parts  to  the  bone  at  the  junction  of  the  upper 
with  the  middle  thirds  of  the  thigh,  and  is  combined 
with  a  vertical  incision  over  the  great  trochanter, 
through  which  the  upper  extremity  of  the  femur  is 


Chap.  xix.        The  Region  of  the  Hip.  457 

exposed  and  the  joint  disarticulated.  (See  section, 
Fig.  59.)  Haemorrhage  from  the  femoral,  gluteal, 
and  sciatic  vessels  is  prevented  either  by  compressing 
the  termination  of  the  abdominal  aorta  a  little  below 
and  to  the  left  of  the  umbilicus,  or  by  encircling  the 
junction  of  the  thigh  and  body  with  a  loop  of  elastic 
bandage.  The  bandage  must  pass  inside  the  ischial 
tuberosity  to  compress  the  contents  of  the  sacro-sciatic 
foramen,  over  the  groin  to  compress  the  femoral  vessels, 
and  above  the  iliac  crest  to  prevent  it  from  slipping 
downwards.  In  the  circular  incision  the  vessels  divided 
are :  the  superficial  and  deep  femoral,  the  second  per- 
forating artery,  descending  branches  of  the  external 
circumflex  and  sciatic  vessels,  and  long  saphenous  vein  ; 
the  nerves  divided  are  :  the  external,  middle  and 
internal  cutaneous,  the  internal  saphenous,  the  deep 
muscular  branches  of  the  anterior  crural,  the  obturator, 
the  great  and  small  sciatic  ;  the  muscles  divided  are  : 
the  sartorius,  quadriceps  extensor  cruris,  adductors 
magnus  and  longus,  gracilis,  and  hamstrings.  In  the 
vertical  incision  (Fig-  59)  the  ilio-tibial  band  and  the 
insertions  of  all  the  gluteal  muscles  are  divided  to  the 
bone.  Communicating  branches  between  the  ascending 
and  transverse  branches  of  the  external  circumflex 
artery  in  front  with  the  gluteal  sciatic  and  first  per- 
forating behind  are  cut.  The  capsule  of  the  joint  is 
divided,  the  head  of  the  femur  thrust  from  its  socket, 
and  the  ligamentum  teres  cut.  The  attachments  of 
the  following  structures  to  the  upper  third  of  the 
femur  have  to  be  separated  :  the  gluteus  maximus, 
medius,  minimus,  pyriformis,  gemelli,  obturator  in- 
ternus  and  externus,  quadratus  femoris,  adductor 
magnus,  brevis,  pectineus,  psoas  and  iliacus,  with  the 
capsular  ligament. 

By  the  method  of  disarticulation  at  the  hip-joint 
known  as  the  anterior  racket,  no  elastic  tourniquet 
and  no  compression  of  the  iliac  vessels  are  needed. 

The  vertical  part  of  the  racket-shaped  incision  is 
placed  over  the  femoral  vessels,  and  those  vessels  are 
secured   by  two  ligatures  each  and  are  then  severed 


458  Surgical  Applied  Anatomy.     [Chap.  xx. 

between  the  ligatures.     The  circumflex  arteries  are  in 
the  same  way  secured  before  division. 

If  carefully  performed,   very  little  blood  is  lost  in 
the  anterior  racket  amputation. 


CHAPTER     XX. 

THE   THIGH. 

Undee  the  term  "  the  thigh  "  it  will  be  convenient 
to  describe  that  part  of  the  lower  limb  that  extends 
between  the  regions  just  described  and  the  districts 
of  the  knee  and  popliteal  space. 

Surface  anatomy.— In  muscular  subjects  the 
outline  of  the  thigh  is  irregular,  but  in  the  less  mus- 
cularly  developed,  who  are  provided  with  a  good  share 
of  subcutaneous  fat,  the  limb,  in  this  section  of  it,  is 
more  or  less  evenly  rounded.  The  prominence  of  the 
rectus  muscle  is  noticeable  on  the  front  of  the  thigh, 
especially  when  the  muscle  is  in  action.  To  the  inner 
side  of  this  structure,  and  conspicuous  along  the  lower 
half  of  the  thigh,  is  the  eminence  formed  by  the  vastus 
internus.  The  mass  to  the  outer  side  of  the  rectus  is 
composed  of  the  external  vastus  muscle,  and  occupies 
the  greater  part  of  the  limb  in  this  region,  being,  how- 
ever, more  conspicuous  below. 

Running  down  the  anterior  and  inner  aspect  of 
the  thigh,  from  the  apex  of  Scarpa's  triangle,  is  a  depres- 
sion which  indicates  the  interval  between  the  quadriceps 
muscle  and  the  adductors.  Along  this  groove  the 
sartorius  lies.  Over  the  surface  of  the  vastus  internus 
a  longitudinal  depression  is  often  to  be  observed,  formed 
by  the  pressure  exercised  by  the  superimposed  ilio-tibial 
band  of  the  fascia  lata.  The  hamstring  muscles  cannot 
usually  be  distinguished  the  one  from  the  other  above 
the  popliteal  space,  nor  is  their  separation  from  the 
adductors  indicated.  The  separation,  however,  between 
them  and  the  vastus  externus  is  distinct,  and  corre- 


Chap,  xx.]  The   Thigh.  459 

spends  to  t  lie  position  of  the  external  inter-muscular 
septum.  The  line  of  the  femoral  vessels  has  already 
been  given.  The  long  saphenous  vein  follows  in  the 
thigh  the  course  of  the  sartorius  muscle,  and  may  be 
represented  on  the  surface  by  a  line  drawn  from  the 
region  of  the  saphenous  opening  (page  432)  to  the 
posterior  border  of  the  sartorius  muscle  at  the  level 
of  the  inner  condyle  of  the  femur.  The  long  saphenous 
nerve  follows  the  course  of  the  femoral  artery,  lying 
first  to  the  outer  side  of  that  vessel  and  then  gradually 
crossing  it.  In  the  lower  fourth  of  the  thigh  the  nerve 
passes  under  cover  of  the  sartorius  muscle  to  the  inner 
side  of  the  knee,  and  is  accompanied  by  the  superficial 
branch  of  the  anastomotic  artery.  A  line  drawn  down 
the  back  of  the  limb  from  a  point  midway  between  the 
great  trochanter  and  tuber  ischii  to  the  middle  of  the 
ham  will  correspond  to  the  great  sciatic  nerve  and  one 
of  its  continuations,  the  internal  popliteal.  The  great 
trunk  usually  bifurcates  a  little  below  the  middle  of  the 
thigh. 

The  skin  of  the  thigh  is  coarse  on  the  outer  side 
of  the  limb,  but  internally  it  is  thin  and  fine,  and  is 
apt  to  be  readily  excoriated  by  ill-applied  bandages  or 
splints.  It  is  but  loosely  attached  to  the  subjacent 
parts,  a  circumstance  that  greatly  favours  the  perform- 
ance of  circular  amputations  in  this  region.  At  one 
place,  however,  it  is  a  little  more  adherent,  viz.,  along 
the  groove  that  separates  the  vastus  externus  behind 
from  the  hamstring  muscles,  and  that  corresponds  to  the 
outer  intermusciuar  septum.  The  laxity  of  the  sub- 
cutaneous tissue  favours  extensive  extravasations  be- 
neath the  skin,  and  permits  of  large  flaps  of  integument 
being  torn  up  in  cases  of  injury  to  this  part  of  the 
extremity. 

The  fascia  lata  invests  the  limb  at  all  parts  like 
a  tightly  fitting  sleeve.  It  is  thickest  at  its  outer  side, 
where  it  forms  the  dense  ilio-tibial  band.  It  is  thinnest 
at  the  upper  and  inner  aspect  of  the  thigh,  where  it 
covers  the  adductor  muscles.  It  increases  considerably 
in  strength  as  it  approaches  the  front  of  the  knee,  and 


460  Surgical  Applied  Anatomy.     [Chap.  xx. 

attaches  itself  to  the  tibia  and  lateral  margins  of  the 
patella.  This  fascia  resists,  especially  at  its  outer  part, 
the  growth  of  tumours  and  abscesses,  and  limits  deep 
extravasations  of  blood.  It  has  occasionally  been  rup- 
tured in  part  by  violence,  and  through  the  rent  so  formed 
the  subjacent  muscle  has  bulged,  forming  what  is  known 
as  a  hernia  of  the  muscle.  This  condition  has  been 
met  with  in  the  case  of  the  quadriceps  muscle,  and  also 
of  the  adductor  longus.  Such  "  hernial  "  are  probably 
associated  with  some  rupture  of  the  fibres  of  the  muscles 
implicated.  Two  deep  processes  of  the  fascia  are  attached 
to  the  femur,  and  form  the  outer  and  inner  intermuscular 
septa.  The  outer  septum  separates  the  vastus  externus 
from  the  biceps,  and  the  inner  the  vastus  interims  from 
the  adductors.  Together  with  the  fascia  lata,  these 
septa  divide  the  thigh  into  two  aponeurotic  spaces, 
which  can  be  displayed  in  a  transverse  section  of  the 
limb.  These  divisions,  however,  are  of  little  surgical 
moment,  and  the  inner  septum  is  often  so  thin  and  feeble 
that  it  could  have  little  effect  in  directing  the  course 
of  an  abscess. 

In  circular  amputations  of  the  thigh  the  muscles 
are  apt  to  retract  a  little  unevenly,  since  some  are 
attached  to  the  femoral  shaft  while  others  are  free. 
The  muscles  so  attached  are  the  adductors,  vasti  and 
crureus,  while  the  free  muscles  are  the  sartorius,  rectus, 
hamstrings,  and  gracilis. 

In  spite  of  its  great  strength  the  tendon  of  the  quadri- 
ceps may  be  ruptured  by  muscular  violence.  A  good 
example  of  such  an  accident  is  recorded  by  Mr.  Bryant 
(Med.  Times,  1878).  A  man  aged  forty-two  stumbled 
in  the  dark,  and  fell  down  a  pit  ten  feet  deep.  On 
examination  the  tendon  was  found  to  be  torn  across, 
and  the  gap  above  the  patella  produced  by  the  rupture 
occupied  no  less  extent  than  the  lower  third  of  the  thigh. 
A  somewhat  more  remarkable  accident  is  reported  to 
have  happened  to  the  sartorius  muscle.  This  muscle, 
just  before  its  insertion  into  the  tibia,  gives  off  an  apo- 
neurotic expansion  from  its  anterior  border  to  the  capsule 
of  the  knee-joint.     In  the  case  alluded  to  (Lancet,  1873), 


chap,  xx.]  The  Thigh.  461 

this  expansion  is  said  to  have  been  ruptured,  and  the 
muscle  itself  to  have  been  found  dislocated  backwards 
in  consequence.  The  accident  befell  a  man  aged  forty, 
who  was  squatting,  in  the  position  assumed  by  tailors, 
upon  the  floor  of  a  waggon,  when  his  companion  tripped 
over  him  and  fell  across  his  bent  knees.  Something 
was  felt  to  have  given  way  near  the  ham,  and  on  examina- 
tion the  above  lesion  was  diagnosed. 

The  femoral  artery  may  be  ligatured  at  any  part 
of  its  course  in  the  thigh,  and  the  comparatively  super- 
ficial position  of  the  vessel  renders  it  very  liable  to  be 
injured.  In  the  middle  third  of  the  thigh  it  lies  beneath 
the  sartorius  in  Hunter's  canal.  The  thigh  affords  many 
instances  of  the  remarkable  way  in  which  isolated 
branches  of  a  main  artery  are  often  alone  damaged. 
Thus,  Langier  relates  the  case  of  a  man-cook,  who,  in 
running  round  a  table,  struck  the  upper  and  outer  side 
of  his  thigh  against  the  corner  of  it.  This  led  to  a  sub 
cutaneous  rupture  of  the  external  circumflex  artery. 
Unfortunately  the  extravasation  was  cut  into,  and  the 
patient,  after  being  subjected  to  many  modes  of  treat- 
ment, died  from  the  effects  of  repeated  haemorrhage. 
Dr.  Butcher  (Dub.  Jour  11.  Med.  Sc,  1874)  gives  the 
case  of  a  man  who  was  stabbed  in  the  thigh  over  the 
femoral  vessels  during  a  scuffle.  Profuse  bleeding  followed, 
and  it  was  found  that  the  only  vessel  wounded  was  the 
internal  circumflex  artery,  just  at  its  point  of  origin 
from  the  profunda.  The  case  was  treated  promptly 
and  the  man  did  well. 

Fractures  of  the  femur. — The  shaft  of  the 
femur  may  be  broken  at  any  part,  but  the  lesion  is 
most  common  at  the  middle  third  of  the  bone,  and 
least  frequent  at  its  upper  third.  If  broken  by  direct 
violence  the  fracture  is  usually  transverse,  and  if  by 
indirect  violence  it  is  usually  oblique.  The  probability 
of  a  fracture  being  due  to  direct  violence  diminishes 
in  the  bone  from  below  upwards,  while  the  probability 
of  a  lesion  from  indirect  violence  increases  in  the 
same  direction.  Thus  it  happens  that  the  fractures 
of  the  upper  third    of    the    bone  are  usually  oblique, 


462  Surgical  Applied  Anatomy.     [Chap.  xx. 

while  those  of  the  lower  third  are  more  commonly 
transverse.  In  the  middle  third  the  numbers  of  the 
transverse  and  oblique  fractures  are  more  nearly 
balanced.  The  femur  has  often  been  broken  by  mus- 
cular violence,  but  it  is  doubtful  if  this  has  ever 
occurred  in  other  than  a  diseased  bone.  In  many  of 
these  cases  the  amount  of  force  that  breaks  the  bone 
is  most  insignificant.  Thus  Vallin  reports  the  case  of 
a  girl  aged  eighteen,  described  as  robust,  who  broke  the 
femur  about  its  middle  while  in  the  act  of  mounting 
a  table  for  the  purpose  of  undergoing  a  vaginal  examina- 
tion. In  oblique  fractures  in  the  upper  third  of  the  bone 
the  line  of  fracture  usually  runs  downwards  and  inwards, 
while  in  oblique  fractures  of  the  middle  third  the  direc- 
tion is  more  commonly  downwards  and  forwards,  with 
a  slight  lateral  inclination  that  is  sometimes  inwards 
and  sometimes  outwards.  Fractures  of  the  lower  third 
of  the  bone  are  discussed  in  connection  with  the  region 
of  the  knee  (chap.  xxi.). 

With  regard  to  fractures  of  the  upper  and  middle 
thirds,  the  displacements  of  the  fragments  depend 
greatly  upon  the  obliquity  of  the  fracture.  As  a  rule 
the  lower  fragment  is  drawn  up  behind  the  upper  one 
by  the  hamstrings,  aided  by  the  rectus,  gracilis, 
sartorius,  tensor  vaginae,  and  adductors,  and  is  carried 
a  little  to  its  inner  side  under  the  influence  of  the  last- 
named  muscles.  The  lower  end  of  the  upper  fragment 
usually  projects  forwards  and  a  little  outwards.  This 
is  produced  by  the  agency  of  the  lower  fragment,  which 
tilts  the  upper  piece  of  bone  in  the  direction  named. 
In  the  fracture  of  the  upper  third  of  the  shaft  the  pro- 
jection forwards  of  the  upper  fragment  is  aided  by  the 
ilio-psoas  muscle.  Thus  the  deformity  produced  in 
fractures  of  the  femoral  shaft  is  usually  angular  in 
character.  The  eversion  of  the  foot  noted  in  fractures 
of  the  femur  is  due  to  the  weight  of  the  limb,  which 
causes  the  helpless  member  to  roll  out,  aided  probably 
by  the  action  of  the  external  rotator  muscles. 

Certain  spiral  fractures  (helicoidal  fractures  of 
Leriche)  may  be  produced  in  the  lower  part  of  the  shaft 


Chap.  XX.] 


The  Thigh. 


463 


as  the  result  of  torsion.  M.  Fere  finds  by  experiment 
that  if  the  limb  be  carried  forwards  in  front  of  the 
opposite  knee,  and  the  foot  rotated  outwards,  a  spiral 
fracture  can  be  produced  at  the  junction  of  the  lower 
and  middle  thirds  of  the  femur.  A  like  fracture  at 
the  same  level,   but   with   the  direction  of  the  spiral 


,a         /i 


Fig.  60.  —Trjnsverse  Sectiou  through  the  Middle  of  the  Thigh 
(Braune). 

c  Rectus  feraoris ;  b,  vastus  extenraa ;  c,  crureus;  d,  vastus  interims }  e,  snort 
'  bead  of  biceps;  f,  long  bead  of  biceps ;  a,  semitendinosus  :  fc,6emimenibra< 
nosus:  i,  adductor  magnus;  3, gracilis;  k,  adductor  longus;  I,  sartonus :  1, 
femoral  artery;  2,  great  sciatic  nerve;  3,  great  saphenous  vein;  4,  middle 
cutaneous  nen  e :  5.  external  cutaneous  nerve  ;  6,  perforating  branches  from 
profunda:  7,  small  sciatic  nerve. 


reversed,  can  be  produced  by  carrying  the  limb  outwards 
and  then  rotating  it  inwards. 

Shortening    of  the    limb   after  fraeture.— 

It  is  doubtful  if  a  fracture  of  the  shaft  of  the  femur 
can,  after  any  treatment,  become  united  without  some 
shortening  resulting,  save  in  a  few  exceptional  cases. 
It  is  important,  in  connection  with  this  subject,  to 
remember  that  the  lower  limbs   may   be   normally   of 


464  Surgical  Applied  Ana  to  my.     [Chap.  xx. 

unequal  length.  Dr.  Wight,  of  Brooklyn,  has  fully  in- 
vestigated this  matter,  and  has  arrived  at  the  following 
conclusions  :  (1)  The  greater  number  of  normal  lower 
limbs  are  of  unequal  length  ;  (2)  the  left  limb  is  often 
longer  than  the  right ;  (3)  the  average  inequality  of 
normal  lower  limbs  is  probably  about  \  of  an  inch  ; 
(4)  the  average  amount  of  shortening  after  a  fracture 
of  the  femur  that  has  been  well  treated  is  about  §  of 
an  inch  ;  (5)  in  about  one  case  in  ten  or  eleven  the 
two  limbs  will  be  found  to  be  of  equal  length  after  the 
union  of  the  fracture  ;  (6)  one  limb  can  never  be  a 
certain  standard  of  length  for  the  opposite  limb.  Dr. 
Garson,  as  a  result  of  the  careful  examination  of  some 
seventy  skeletons,  states  that  both  the  lower  limbs  are 
of  equal  length  in  only  about  10  per  cent,  of  all  cases. 
He  also  found  that  the  femur  was  more  frequently 
the  seat  of  variation  than  the  tibia. 

Amputation  oi  the  thigh. — In  a  circular 
amputation  of  the  thigh  about  its  middle  the  following 
parts  would  be  divided  (Fig.  60) :  the  quadriceps,  sar- 
torius,  gracilis,  long  and  great  adductors,  and  the  three 
hamstring  muscles  ;  the  femoral  and  profunda  vessels, 
the  descending  branches  of  the  external  circumflex 
artery,  the  lower  perforating  vessels,  and  the  long 
saphenous  vein  ;  the  main  branches  of  the  anterior 
crural  nerve  (middle  cutaneous,  internal  cutaneous, 
and  muscular,  together  with  the  long  saphenous  nerve), 
the  anterior  branch  of  the  external  cutaneous  nerve, 
the  obturator,  and  the  great  and  small  sciatic  nerves. 
Owing  to  the  unequal  manner  in  which  the  divided 
muscles  retract,  a  simple  circular  amputation  is  not 
well  adapted  for  the  thigh.  A  more  convenient  method 
of  amputation  is  represented  by  the  elliptical  method, 
the  lower  extremity  of  the  ellipse  being  on  that  side 
of  the  limb  on  which  muscular  retraction  is  the  more 
marked,  i.e.  on  the  posterior  side  of  the  thigh.  "/ 


465 

CHAPTER  XX!. 

THE    REGION    OF   THE    KNEE. 

In  this  chapter  will  be  considered  the  articulation 
of  the  knee,  the  soft  parts  about  the  joint,  the  popliteal 
Space,  the  lower  end  of  the  femur,  the  patella,  and  the 
upper  ends  of  the  tibia  and  fibula. 

Surface  anatomy. — In  the  front  of  the  knee 
the  patella  can  be  distinctly  felt  and  seen.  Its  inner 
border  is  a  little  more  prominent  than  the  outer.  When 
the  limb  lies  in  the  extended  posture,  with  the  quadriceps 
relaxed,  the  patella  can  be  moved  to  and  fro,  and  appears 
to  be  but  loosely  attached.  When  the  quadriceps  is 
contracted  the  bone  is  drawn  upwards,  and  becomes 
firmly  fixed  against  the  femur.  In  flexion  of  the  joint 
the  patella  sinks  into  the  hollow  between  the  tibia  ami 
the  intercondyloid  notch,  and  is  very  firmly  fixed 
In  this  position  some  part  of  the  trochlear  surface  of 
the  femur  can  be  made  out  above  the  patella.  On  each 
side  of  the  knee-cap  a  hollow  exists  which  may  be  com- 
pletely filled  up  with  fat  in  the  obese. 

When  the  limb  lies  in  the  extended  posture  the 
ligamentum  patellaf  is  not  to  be  very  distinctly  made 
out.  It  becomes  a  little  more  conspicuous  in  the  flexed 
position,  and  is  most  prominent  when  the  quadriceps 
muscle  is  vigorously  contracted. 

On  the  inner  side  of  the  knee  the  following  parts 
can  be  felt  from  above  downwards:  the  tubercle  for 
the  adductor  magnus,  and  the  tendon  of  insertion  of 
that  muscle  ;  the  inner  condyle  of  the  femur,  which  is 
very  prominent,  and  forms  the  chief  part  of  the  rounded 
eminence  on  this  aspect  of  the  joint ;  and  below  this 
the  inner  tuberosity  of  the  tibia.  Between  the  two 
latter  processes  of  bone  the  interarticular  line  is  easily 
to  be  felt.  On  the  outer  side  of  the  joint  is  the  external 
condyle  of  the  femur,  which  is  much  less  conspicuous 
than  its  fellow  of  the  opposite  side,  and  below  it  is  the 


466  Surgical  Applied  Anatomy,   tchap.  xxi. 

corresponding  tuberosity  of  the  tibia,  forming  a  marked 
prominence.  Immediately  in  front  of  the  biceps  tendon 
the  upper  part  of  the  external  lateral  ligament  can  be 
felt  when  the  joint  is  a  little  flexed.  Between  the  tendon 
and  the  patella,  the  lower  part  of  the  ilio-tibial  process 
of  the  fascia  lata  can  be  detected  as  a  prominent  rounded 
band,  descending  to  the  external  tuberosity  of  the  tibia. 
It  is  most  distinct  when  the  knee-joint  is  forcibly 
extended  by  muscular  action,  and  often  stands  out 
conspicuously  beneath  the  skin.  The  tubercle  of  the 
tibia  and  the  head  of  the  fibula  are  both  to  be  readily 
felt,  and  are  nearly  on  the  same  level. 

The  popliteal  space  only  appears  as  a  hollow  when 
the  knee  is  bent.  In  the  extended  limb  the  hollow  is 
replaced  by  an  evenly  rounded  eminence.  The  crease 
in  the  skin  that  passes  transversely  across  the  ham  is 
some  way  above  the  line  of  the  knee-joint.  On  the 
outer  side  of  the  space  the  biceps  tendon  can  be  very 
readily  felt,  especially  when  the  muscle  is  in  action. 
Just  behind  it,  and  along  its  inner  border,  lies  the 
peroneal  nerve.  It  can  be  rolled  under  the  finger  as 
it  crosses  the  head  of  the  fibula  to  pass  beneath  the 
peroneus  longus  muscle.  On  the  inner  side  of  the 
ham  three  tendons  can  be  felt.  Nearest  to  the  middle 
of  the  space  is  the  long  prominent  tendon  of  the 
semitendinosus.  Internally  to  it  is  the  larger  and 
less  distinct  semimembranosus  tendon,  and  still  more 
to  the  inner  side  the  gracilis  may  be  made  out. 

The  popliteal  vessels  enter  the  ham  obliquely  at 
its  upper  and  inner  part,  and  under  cover  of  the 
semimembranosus  muscle.  The  outer  border  of  this 
muscle  is  the  guide'to  the  upper  portion  of  the  artery. 
The  vessels  in  their  descent  reach  a  point  behind  the 
middle  of  the  knee-joint,  and  then  pass  vertically  down- 
wards. The  termination  of  the  popliteal  artery  is  on 
a  level  with  the  lower  part  of  the  tubercle  of  the  tibia. 
When  the  limb  is  flexed,  the  pulsations  of  the  artery 
can  be  felt'and  the  vessel  compressed  against  ther femur 
a  little  below  its  point  of  entry  into  the  popliteal  space. 
The  upper  articular  arteries  run   transversely   inwards 


Chap,  xx i.]      The  Region  of  the  Knee.  467 

and  outwards  just  above  the  femoral  condyles.  The 
lower  articular  arteries  are  also  placed  transversely, 
the  inner  vessels  running  just  below  the  internal 
tuberosity  of  the  tibia,  and  the  outer  just  above  the 
head  of  the  fibula.  The  deep  branch  of  the  anastomotica 
magna  descends  to  the  inner  condyle  of  the  femur  in 
the  substance  of  the  vastus  internus,  and  along  the 
front  of  the  adductor  magnus  tendon.  The  internal 
saphenous  vein  passes  up  along  the  back  part  of  the 
internal  condyle  of  the  femur,  and  then  follows  the 
sartorius  muscle  to  the  thigh.  It  is  just  below  the 
interarticular  line  that  the  long  saphenous  nerve  usually 
joins  the  vein.  The  short  saphenous  vein  follows  the 
middle  line  of  the  calf  just  below  the  ham,  and  pierces 
the  deep  fascia  at  the  lower  part  of  the  popliteal  space. 
This  vessel  is  much  less  conspicuous  than  is  the  long 
saphenous  vein,  and  is,  indeed,  not  often  to  be  seen 
unless  varicose. 

The  internal  popliteal  nerve  descends  in  the  middle 
line,  and  continues  the  line  that  marks  the  course  of 
the  great  sciatic  trunk. 

In  their  normal  condition  the  popliteal  glands  are 
not  to  be  felt. 

The  limits  of  the  synovial  membrane  of  the  knee- 
joint,  and  the  position  of  the  various  bursa?  about  this 
articulation,  will  be  dealt  with  in  some  of  the  subsequent 
paragraphs. 

The  front  of  the  knee.— The  skin  over  the 
front  of  the  knee  is  dense  and  very  movable.  This 
mobility  affords  considerable  protection  to  the  knee- 
joint,  especially  in  stabs  wTith  bluntish  instruments, 
and  in  any  injury  Avhere  the  gliding  movement  of  the 
skin  may  direct  the  violence  away  from  the  articulation. 
The  comparative  looseness  of  the  integument  is  some- 
times utilised  in  the  operation  of  removing  so-called 
"  loose  cartilages  "  from  the  knee-joint.  It  permits  the 
incision  into  the  joint  to  be  very  indirect,  and,  the  skin 
being  dragged  out  of  place  during  the  operation,  it  follows 
that,  when  the  procedure  is  complete,  the  surface  wound 
and   that  in   the  knee  capsule  no  longer  correspond. 


468  Surgical  Applied  Anatomy.    [Chap.  xxi. 

In  flexion,  the  skin  is  drawn  tightly  over  the  patella, 
and,  as  is  the  case  elsewhere,  where  integument  lies 
more  or  less  directly  upon  the  bone,  a  contusion  over 
the  knee-cap  may  produce  a  lesion  precisely  like  an 
incised  wound. 

In  the  Lancet  for  1877  is  recorded  the  case  of  a  very 
stout  woman,  aged  fifty-seven,  who,  stumbling  on  a 
hard  road,  fell  upon  her  bent  knee.  The  skin  was  burst 
across  the  front  of  the  knee,  and  a  wound  was  produced 
that  was  7  inches  in  length,  and  was  as  cleanly  cut  as  if 
made  by  a  scalpel. 

There  is  but  little  subcutaneous  fat  in  front  of  the 
articulation,  and  thus  it  happens  that  in  amputations 
through  the  knee-joint  the  anterior  flap  is  very  thin,  and 
is  composed  of  little  other  than  the  simple  integument. 

As  blisters,  and  various  forms  of  counter-irritant, 
are  often  applied  to  the  front  of  the  knee  in  cases  of 
disease,  it  may  be  well  to  take  note  of  the  blood-supply 
of  this  part,  and  of  the  relations  between  the  surface 
vessels  and  nerves  and  those  of  the  joint.  The  vessels 
that  give  branches  to  the  front  of  the  knee,  and  that 
are  concerned  in  the  supply  of  the  part  to  which  blisters 
are  usually  applied,  are  the  anastomotic,  the  four  ar- 
ticular branches  of  the  popliteal,  and  the  anterior  tibial 
recurrent.  Now  of  these  arteries,  and  especially  of  the 
anastomotica  magna  and  superior  articular,  it  may  be 
said  that,  shortly  after  their  origin,  they  divide  into 
two  branches,  or  two  sets  of  branches,  one  going  to  the 
surface  and  the  other  to  the  articulation  of  the  knee 
and  deeper  parts  about  it.  It  may  be  supposed,  there- 
fore, that,  in  applying  a  counter-irritant  in  front  of  the 
knee  for  the  relief  of  a  joint  affection,  a  greatly  increased 
quantity  of  blood  is  drawn  into  the  superficial  divisions 
of  the  above-named  vessels,  and  less  blood  is  thereby 
left  to  flow  by  their  deeper  branches  to  the  seat  of  disease. 
The  skin  over  the  front  of  the  knee  is  supplied  by  nerves 
from  the  third  lumbar  segment  (Head).  Through  the 
obturator  nerve  the  joint  is  also  partly  supplied  from 
this  segment. 

The  superficial  lymphatics  in  the  region  of  the  knee 


Chap,  xxi.]      The  Region  of  the  Knee.  469 

lie  for  the  most  part  on  the  inner  aspect  of  the  joint, 
and  follow  the  course  of  the  long  saphenous  vein. 
Ulcers,  and  other  inflammatory  affections  of  the  skin 
over  the  articulation,  are  more  apt  to  be  associated 
with  lymphangitis  and  with  enlargement  of  the  inguinal 
glands  when  situate  on  the  inner  aspect  of  the  joint 
than  when  placed  in  front  or  to  the  outer  side  of  it. 

The  bursa?  over  the  front  of  the  knee. — (1)  The 
patellar  bursa  is  a  large  sac  placed  in  front  of  the  patella 
and  upper  part  of  the  patellar  ligament,  and  separates 
those  structures  from  the  skin.  It  is  frequently  divided 
by  septa  into  superficial  and  deep  compartments.  It  is 
very  often  found  enlarged  in  those  who  kneel  much,  in 
housemaids,  stone-masons,  religieuses,  etc.  The  parts 
about  are  well  supplied  with  nerves,  and  hence  much 
pain  is  usually  associated  with  acute  inflammation  of 
this  sac.  It  is  in  close  contact  with  the  patella,  and, 
in  one  case  reported  by  Erichsen,  suppuration  of  the 
bursa  led  to  caries  of  that  bone  (Figs.  61,  62,  and  65). 

(2)  There  is  a  small  bursa  between  the  patellar  ligament 
and  the  tubercle  of  the  tibia  (Fig.  62).  When  inflamed, 
it  causes  more  pain  than  is  observed  in  affections  of  the 
previous  bursa,  since  it  is  firmly  compressed  between 
two  rigid  structures,  the  ligament  and  the  bone.  It  is 
separated  from  the  synovial  cavity  by  the  pad  of  fat  that 
lies  behind  the  patella.  It  would  appear,  however,  to 
sometimes  communicate  with  the  joint,  since  Hamilton 
has  collected  three  cases  where  incision  into  this  bursa 
led  to  suppuration  of  the  articulation.  There  is  a  pad 
of  soft  fat  between  the  ligament  and  the  tibial  tubercle, 
which  often  protrudes  a  little  at  either  side  of  the  former 
structure,  and  lias  been  mistaken  for  an  enlarged  bursa . 

(3)  The  bursa  between  the  quadriceps  tendon  and  the 
femur  will  be  considered  in  connection  with  the  synovial 
cavity. 

The  popliteal  space. — The  skin  over  the 
space  is  not  so  movable  as  is  that  over  the  front  of  the 
knee.  When  destroyed  by  injury,  by  burns,  or  by 
extensive  ulceration,  the  contraction  of  the  resulting 
cicatrix  may  lead  to  a  rigidly  bent  knee.     The  skin  in 


47°  Surgical  Applied  Anatomy.    [ChaP.  xxi. 

this  place  has  also  been  ruptured  by  forcible  extension 
applied  to  the  limb  in  cases  of  contracted  knee.  Beneath 
the  skin  and  superficial  tissue  is  the  popliteal  fascia, 
a  dense  membrane  that  covers  in  the  space.  It  is  but 
a  continuation  of  the  fascia  lata  of  the  thigh,  and  is 
continuous  below  with  the  fascia  of  the  leg.  It  passes 
without  bony  attachment  over  the  hamstring  muscles 
that  bound  the  ham.  This  fascia  limits,  often  in  a  very 
marked  manner,  the  progress  of  popliteal  abscesses 
and  growths  towards  the  surface.  Its  unyielding 
character  is  a  prime  cause  in  the  production  of  the  severe 
pain  with  which  such  collections  and  tumours  are  often 
associated.  The  popliteal  abscess,  unable  to  reach  the 
surface,  is  encouraged  to  extend  either  up  into  the  thigh 
or  down  the  leg.  The  ham  may  hold  a  very  considerable 
quantity  of  pus.  Velpeau  has  seen  a  case  where  a  litre 
(1  pint,  15  oz.)  of  pus  was  evacuated  from  this  region 
in  a  patient  who  presented  before  the  operation  but  an 
insignificant  swelling  in  the  site  of  the  collection.  Duplay 
records  two  cases  of  ulceration  of  an  abscess  into  the 
popliteal  artery,  and  Ollivier  an  instance  where  the 
abscess,  unable  to  find  a  way  to  escape,  ultimately 
entered  into  the  knee-joint. 

Pus  may  reach  the  ham  from  the  buttock  or  pelvis 
by  following  the  great  sciatic  nerve,  or  may  extend 
from  the  thigh  through  the  opening  in  the  great 
adductor  for  the  femoral  vessels. 

The  hamstring  nmscEes  are  frequently  found 
contracted  in  neglected  cases  of  knee-joint  disease,  and 
produce  thereby  more  or  less  rigid  flexion  of  the  leg 
upon  the  thigh.  Irritation  from  disease  of  the  knee- 
joint  may  lead  to  contracture  of  the  hamstring  muscles. 
These  muscles  are  supplied  through  the  great  sciatic 
nerve  from  the  fifth  lumbar  segment,  from  which 
the  knee-joint  derives  in  part  its  nerve  supply.  Muscles 
on  the  flexor  aspect  of  a  bent  joint  undergo  a  permanent 
shortening  if  the  position  be  maintained  for  a  consider- 
able space  of  time. 

Contraction  of  these  muscles  in  knee-joint  disease 
tends  not  only  to  flex  the  knee  but  also  to  draw  the 


chap,  xxi.]      The  Region  of  the  Knee.  471 

tibia  backwards,  and  produce  in  some  cases  a  partial 
luxation. 

The  hamstring  tendons  may  be  ruptured  by 
violence,  the  tendon  most  frequently  torn  being  that 
of  the  biceps.  The  muscles  are  greatly  stretched  when 
the  trunk  is  bent  forcibly  forwards  at  the  hip-joint, 
the  knee  remaining  extended.  Extreme  movement  in 
this  position  has  ruptured  some  of  the  fibres  of  this 
muscle.  The  difficulty  experienced  in  touching  the 
toes  with  the  fingers  while  the  knees  are  kept  stiff 
depends  upon  the  resistance  offered  by  the  stretched 
hamstrings.  In  tenotomy  of  the  biceps  tendon  the 
peroneal  nerve  is  in  great  risk  of  being  wounded.  It 
may  be  noted  that  contraction  of  the  muscle  tends  to 
increase  the  distance  between  the  tendon  and  the 
nerve,  and  to  render  the  former  more  superficial.  The 
peroneal  nerve  is  in  still  greater  risk  of  being  wounded 
in  resecting  the  head  of  the  fibula,  an  operation,  how- 
ever, that  is  seldom  performed. 

The  vessels  of  the  ham. — The  popliteal  vessels 
are,  from  their  depth,  but  seldom  wounded.  It  must 
be  borne  in  mind  that  the  lower  part  of  the  artery  may 
be  reached  from  the  anterior  aspect  of  the  leg  by  an 
instrument  passing  between  the  tibia  and  fibula. 
Thus  Spence  reports  the  case  of  a  farmer  who  received 
a  wound  in  front  of  the  leg,  just  below  the  knee,  from 
the  slipping  of  his  knife  while  cutting  a  stick.  It  was 
discovered  subsequently  that  the  knife  had  entered 
the  interosseous  space  and  had  wounded  the  popliteal 
artery  at  its  bifurcation.  It  had  indeed  nearly  severed 
the  anterior  tibial  artery  from  the  main  trunk. 

The  popliteal  artery  has  been  ruptured  by  external 
violence,  as  when  a  wheel  has  passed  over  the  region 
of  the  vessel.  Mr.  Harrison  Cripps  (Lancet,  1876) 
believes  that  the  rupture  is,  as  a  rule,  the  result  of  a 
force  acting  in  an  oblique  direction  from  below  upwards 
upon  the  lower  expanded  end  of  the  femur.  This 
artery  is  more  frequently  the  seat  of  aneurism  than  is 
any  other  artery  in  the  body,  save  only  the  thoracic 
aorta.     In  551  cases  of  spontaneous  aneurism,  collected 


47 2  Surgical  Applied  Anatomy.   [Chap.  xxi. 

by  Crisp,  the  popliteal  vessel  was  the  seat  of  the  disease 
in  137  instances,  the  thoracic  aorta  having  been  affected 
in  175  of  the  cases.  This  marked  disposition  to  aneurism 
depends  upon  many  factors.  The  vessel  is  subjected 
to  a  great  deal  of  movement,  and  often  to  very  violent 
movement.  Experiments  upon  the  dead  body  show 
that  the  inner  and  middle  coats  of  the  vessel  may  be 
ruptured  by  extreme  flexion  of  the  knee,  and  that  a 
like  rupture  may  in  a  smaller  percentage  of  cases  be 
brought  about  by  forcible  extension.  Moreover,  except 
when  the  limb  is  in  the  position  of  extension  the  popliteal 
artery  is,  like  the  thoracic  aorta,  much  curved.  Then, 
again,  the  vessel  breaks  up  into  two  large  vessels,  and 
it  is  well  known  that  the  point  of  bifurcation  of  an 
artery  is  a  favourite  spot  for  aneurism.  Lastly,  the 
artery  is  supported  only  by  the  lax  tissue  of  the 
popliteal  space,  and  the  support  of  strong  muscles  given 
elsewhere  to  so  many  large  vessels  is  practically  absent. 
Some  popliteal  aneurisms  have  been  successfully  treated 
by  flexing  the  knee  and  retaining  the  limb  for  some 
time  in  that  position.  That  flexion  can  have  a  direct 
effect  upon  the  lumen  of  the  vessel  is  shown  by  the 
diminished  pulse  at  the  inner  ankle  produced  by 
forcibly  bending  the  leg  upon  the  thigh.  The  artery 
and  vein  are  so  adherent  that  it  is  difficult  to  separate 
the  two  when  applying  a  ligature  to  the  arterial  trunk. 
This  adhesion  must  have  been  appreciated  by  any  who 
have  taken  pains  to  "  clean  "  the  artery  in  a  dissection 
of  the  ham. 

The  popliteal  vein  is  a  remarkably  substantial  vessel, 
and  has  walls  so  dense  and  thick  that  on  section  they 
often  look  more  like  the  tunics  of  an  artery.  On  the 
ground  of  this  peculiarity,  and  of  its  close  adhesion 
to  its  companion  vessel,  Tillaux  asserts  that  "  it  is  unlike 
any  other  vein  in  the  economy."  It  is  worthy  of  note 
that  the  vein,  although  more  superficial  than  the  artery, 
is  very  rarely  ruptured  by  violence.  As  a  rule,  the 
artery  alone  is  torn.  In  a  few  cases  both  the  vessels 
may  suffer  ;  but  I  can  find  no  instance  recorded  of 
rupture  of  the  popliteal  vein  alone. 


Chap,  xxi.]     The  Region  of  the  Knee.  473 

From  the  relations  of  the  artery  to  the  vein  and 
nerve  it  will  be  understood  that  a  popliteal  aneurism 
may  soon  lead  to  cedema  of  the  leg  and  to  nerve  symptoms 
depending  upon  pressure  on  the  internal  popliteal  trunk. 
It  has  more  than  once  also  made  its  way  into  the  knee- 
joint,  with  the  posterior  ligament  of  which  the  artery 
is  in  such  close  relation. 

The  short  saphenous  vein  lies  almost  in  the  middle 
line,  and  not  being  usually  apparent  through  the  skin, 
may  be  divided  in  an  incision  made  into  the  lower  part 
of  the  popliteal  space.  Herapat  has  suggested  that 
varices  of  this  vein  may  depend  upon  the  narrowness 
of  the  opening  in  the  fascia  lata  through  which  the 
vessel  passes  to  reach  the  main  trunk. 

The  lymphatic  glands  in  the  ham  are  from 
four  to  five  in  number  and  are  deeply  placed  about 
the  great  vessels.  When  enlarged  they  have  been 
mistaken  for  aneurism  and  other  popliteal  tumours. 
They  receive  the  deep  lymphatics  of  the  leg.  A  small 
gland  is  often  met  with  beneath  the  fascia,  close  to  the 
point  of  entry  of  the  short  saphenous  vein.  It  receives 
some  lymphatics  that  follow  that  vessel. 

The  bursse  about  the  ham  are  usually  six  in 
number,  two  on  the  inner  side  of  the  space  and  four 
on  the  outer.  Inner  side. — (1)  A  large  bursa  between 
the  internal  condyle  of  the  femur  and  the  inner  head 
of  the  gastrocnemius  and  the  semimembranosus.  This 
is  the  largest  bursa  in  the  space,  and  after  adult  life 
it  usually  communicates  with  the  joint.  It  is,  of  all 
the  bursse  in  this  region,  the  one  most  often  enlarged, 
and  when  affected  may  attain  great  size.  In  one 
reported  case  the  sac  measured  5  inches  by  3.5  inches. 
In  the  extended  position  of  the  limb  the  enlarged  bursa 
feels  firm  and  resisting,  but  on  flexion  it  becomes  flaccid 
and  can  often  be  made  to  entirely  disappear.  Probably 
the  slit-like  communication  between  the  bursa  and 
the  joint  is  closed  when  the  posterior  ligament  is 
tightened  by  extension,  and  is  opened  when  it  is  relaxed 
on  bending  the  knee.  In  the  latter  posture  the  contents 
of  the  bursa  can  be  reduced  into  the  cavity  of  the  knee- 


474  Surgical  Applied  Anatomy.   [Chap.  xxi. 

joint,  and  so  the  tumour  disappears.  (2)  A  little  bursa 
between  the  semimembranosus  tendon  and  the  tuberosity 
of  the  tibia.  It  never  communicates  directly  with  the 
joint,  but  has  sometimes  an  opening  into  the  bursa 
just  described.  Outer  side.— {I)  A  bursa  between  the 
popliteus  tendon  and  the  external  lateral  ligament 
that  does  not  usually  communicate  with  the  joint. 
(2)  One  between  the  popliteus  tendon  and  outer 
tuberosity  of  the  tibia,  that  is  merely  a  diverticulum 
from  the  synovial  membrane.  This  sac  may  open 
into  the  tibio-fibular  articulation,  and  so  bring  that 
cavity  in  connection  with  the  knee-joint.  (3)  A  bursa 
between  the  outer  head  of  the  gastrocnemius  and  the 
femoral  condyle.  It  is  not  constant  and  is  not  connected 
with  the  articulation.  (4)  A  bursa  between  the  biceps 
tendon  and  the  external  lateral  ligament.  The  peroneal 
nerve  runs  across  this  sac,  a  circumstance  that  may 
explain  some  of  the  pain  experienced  when  the  bursa 
is  enlarged. 

It  is  not  improbable  that  wounds  of  bursse  in  this 
region  containing  fluid  have  been  mistaken  for  wounds 
of  the  joint,  and  the  escaping  serum  for  synovia. 

The  knee-joint. — This  articulation  is  the  largest 
in  the  body.  The  joint  owes  its  great  strength  to  the 
powerful  ligaments  that  unite  the  two  component  bones, 
and  to  the  muscles  and  fasciae  that  surround  it.  It 
derives  no  strength  from  the  shape  of  the  articular 
surfaces,  since  they  are  merely  placed  in  contact  with 
one  another.  In  spite  of  its  frequent  exposure  to  in- 
jury, dislocations  at  the  knee  are  extremely  rare.  The 
lateral  ligaments  are  comparatively  feeble,  are  tense  in 
extension  and  relaxed  in  flexion.  The  laxity  of  these 
ligaments  is  such  that  partial  luxations  of  the  tibia 
are  possible  without  •  rupture  of  these  bands,  especially 
in  cases  where  the  joint  is  found  slightly  flexed  after 
the  accident.  The  crucial  ligaments  are  very  powerful, 
and  are  more  or  less  tense  in  all  positions  of  the  joint. 
The  anterior  of  these  ligaments  especially  resists 
extension,  forward  displacement  of  the  tibia,  and 
rotation    inwards    of    the    leg.     The    posterior    band 


chap,  xxi.]      The  Region  of  the  Knee. 


475 


resists  flexion  and  displacement  backwards  of  the  tibia. 
In  the  movement  of  extension  the  tibia  slides  a  little 
forwards  and  is  rotated  a  little  outwards.  In  flexion 
that  bone  glides  backwards  and  rolls  a  little  inwards. 
Extension  generally  is  limited  by  the  crucial  and 
posterior  ligaments  ;  flexion  by  the  ligamentum  patella? 
and  anterior  part  of  the  capsule,  in  addition  to  the  crucial 


HH 


fi a 


\~~f 


Fig.  61.— Vertical  Section  of  Normal  Knee-joint  (Braune). 

a,  (Quadriceps;  6,  semimembranosus ;   c,  gastrocnemius;    d,  posterior   crucial 
ligament  ;  e,  ligamentum  patella,' ;  /,  bursa  between  quadriceps  and  femur. 


ligaments.  Rotation  is  possible  only  in  the  flexed 
position.  The  thinnest  part  of  the  posterior  ligament 
is  the  portion  below  the  oblique  fibres  derived  from  the 
semimembranosus.  If  pus  finds  its  way  from  the 
joint  into  the  ham,  it  will  probably  escape  through 
this  part  of  the  ligament. 

In  the  contracted  knee  associated  with  fibrous 
anchylosis,  the  chief  contraction,  so  far  as  the  joint 
tissues  are  concerned,  is  in  the  posterior  ligament,  in 


476  Surgical  Applied  Anatomy.    [Chap.  xxi. 

the  lateral  ligaments,  and  in  the  fibrous  and  fatty  tissue 
between  the  former  ligament  and  the  posterior  crucial 
band. 

The  synovial  membrane  of  the  knee-joint  extends 
upwards  as  a  large  cul-de-sac  above  the  patella  and 
beneath  the  extensor  tendon.  This  cul-de-sac  reaches 
a  point  an  inch  or  more  above  the  upper  margin  of  the 
trochlear  surface  on  the  femur,  and  is  rendered  very 
distinct  when  the  joint  is  distended  with  fluid  (Fig. 
62).  When  the  knee  is  bent  the  cul-de-sac  is  drawn 
down,  and  therefore  this  position  of  the  limb  is 
advised  when  operations  are  about  to  be  performed 
upon  the  lower  end  of  the  femur.  Above  the  synovial 
pouch  is  a  bursa  that  separates  the  quadriceps  tendon 
from  the  femur,  and  is  usually  over  an  inch  in  its  vertical 
measurement  (Fig.  62).  From  the  examination  of 
two  hundred  and  sixty  knee-joints  in  both  infants 
and  adults  Schwartz  found  that  this  bursa  communicated 
with  the  synovial  cavity  in  seven  cases  out  of  ten  in 
young  children,  and  in  eight  cases  out  of  ten  in  adults. 

It  will  thus  be  seen  that  when  this  communica- 
tion exists,  a  stab  over  the  femur,  about  2  inches  above 
the  trochlear  surface  of  the  bone,  or  about  the  same 
distance  above  the  top  of  the  patella,  when  the  limb 
is  extended,  will  practically  open  the  knee-joint. 

Cases  are  reported  of  extravasation  of  blood  into 
this  bursa  that,  although  at  first  limited  to  the  sac, 
have,  on  rough  handling,  extended  into  the  knee-joint, 
a  circumstance  leading  to  the  supposition  that,  in  some 
cases  the  orifice  of  communication  may  be  very  small. 

The  crucial  ligaments,  although  more  or  less  com- 
pletely invested  by  the  synovial  membrane,  are  yet 
entirely  outside  the  synovial  cavity,  and  divide  the 
cavity  behind  into  an  outer  and  inner  condylar  recess. 
The  posterior  ligament  is  continuous  with  the  posterior 
part  of  the  capsule. 

The  upper  third  of  the  patellar  ligament  is  in  relation 
to  the  synovial  membrane,  from  which,  however,  it  is 
separated  by  a  pad  of  fat.  The  lower  two-thirds  of  the 
ligament  are  in  relation  to  the  bursa  and  fatty  tissue 


chap,  xxi.]      The  Region  of  the  Knee. 


All 


that  intervene  between  the  band  and  the  tibia.  A 
knife  passed  horizontally  backwards  at  the  apex  of  the 
patella  would,  when  the  limb  is  extended,  just  miss  the 
joint  line  between  the  femur  and  tibia,  and  would  hit 
the  latter  bone  (Fig.  61).     If,  however,  there  be  any 


Fig.  62.  —Vertical  Section  of  Knea-joint  distended  with  Fluid 
(Braune). 

a,  Vastus  extenms  ;  b,  crureus  :  c,  short  head,  and  rf.  lone  head, of  biceps  ;  e.  plnn- 
taria :/, gastrocnemius ;  g,  popliteus  ;  >>.  soleus;  »',  tibialis  posticus ;  jt bursa 
natcllsa;  Jr,  ligamentum  patellar ;  l,  ligamentiim  luueosum ;  m  anterior  crucial 

lipament:    n,  external    semilunar  cartilage;    l,  external  popliteal  nervt; 

2.  popliteal  artery. 


effusion  in  the  joint,  or  the  limb  be  a  little  flexed,  a  knife 
so  introduced  would  pass  between  the  two  [  bones 
(Fig.  62). 

Joint  disease. — Owing  to  its  superficial  position 
thejmee-joint  is  the  articulation  that  is  most  frequently 


478  Surgical  Applied  Anatomy.   [Chap.  xxi. 

the  seat  of  inflammation  due  to  injury  and  exposure 
to  cold.  When  distended  with  fluid,  the  effusion  soon 
shows  itself  above  and  at  the  sides  of  the  patella,,  by 
bulging  forward  the  synovial  sac,  which  is  here  more 
nearly  in  relation  to  the  surface  than  it  is  elsewhere. 
Fluctuation  is  soon  to  be  detected,  and  the  patella, 
being  pushed  away  from  the  femur,  is  said  to  "  float " 
upon  the  distending  fluid  (Fig.  62). 

The  inflamed  knee-joint,  if  left  to  itself,  almost  in- 
variably assumes  the  flexed  position.  This  may  be 
explained  upon  three  hypotheses,  and  it  is  probable 
that  each  of  the  three  reputed  factors  takes  part  in 
producing  this  position  in  cases  of  disease. 

(1)  The  capacity  of  the  joint  is  increased  on  flexion. 
The  pain  of  acute  synovitis  is  due  mainly  to  the  increasing 
distension  of  the  joint  with  fluid,  and  it  is  natural  that 
the  patient  should  instinctively  place  the  limb  in  the 
position  in  which  the  joint  will  hold  the  greatest  amount 
of  fluid,  and  in  which  the  interarticular  tension  is  reduced 
to  a  minimum.  It  cannot  be  said,  however,  that  the 
greater  the  degree  of  flexion  the  greater  the  capacity 
of  the  joint  cavity.  By  experimental  injections  into 
the  knee,  Braune  found  (a)  "  that  the  capacity  of  the 
synovial  cavity  reaches  its  maximum  in  a  definite  degree 
of  flexion,  and  that  the  angle  at  which  this  happens 
is  twenty-five  degrees  ;  "  (b)  that  "  the  minimum  of  the 
capacity  of  the  synovial  cavity  coincides  with  the  maxi- 
mum of  flexion."  Thus  it  happens  that  the  tension 
within  an  inflamed  knee  will  be  greater  in  extreme 
flexion  than  it  is  in  full  extension. 

(2)  By  flexing  the  limb,  the  more  powerful  liga- 
ments (such  as  the  ligamentum  posticum,  the  posterior 
crucial  and  lateral  ligaments)  are  relaxed,  while  the 
ligaments  rendered  tense  by  the  position  are  the  patellar 
and  the  anterior  part  of  the  capsular,  the  latter  of  which 
is  but  a  yielding  membrane. 

(3)  The  sensory  nerves  of  the  joint  being  disturbed, 
contraction  of  muscles  may  be  anticipated  from  reflex 
action,  and  of  the  muscles  so  excited  the  flexors  may 
be  expected  to  have  the  advantage,  as  being  the  more 


chap,  xxi.]      The  Region  of  the  Knee.  479 

powerful  and  the  more  favourably  placed  for  acting 
upon  the  articulation. 

Dislocation  of  the  semi-lunar  cartilages.— 

One  or  other  of  these  cartilages  may  be  displaced  from 
its  attachments  to  the  tibia,  and  become  nipped  or 
locked  between  that  bone  and  the  femur.  The  result 
is  a  sudden  pain  in  the  limb,  associated  with  a  fixing  of 
the  knee  in  a  flexed  position.  The  accident  is  usually 
brought  about  by  a  twist  given  to  the  leg  when  the 
knee-joint  is  more  or  less  bent.  In  200  cases  of  internal 
derangement  of  the  knee-joint,  Bennett  found  that  the 
internal  cartilage  was  affected  in  155  cases  and  the 
external  in  only  45.  The  left  knee  was  the  seat  of  de- 
rangement nearly  three  times  as  often  as  the  right, 
and  the  lesion  occurred  nine  times  more  frequently 
in  men  than  in  women.  In  every  one  of  twelve  cases 
operated  on  by  Marsh,  the  anterior  extremity  of  the 
internal  semilunar  cartilage  was  found  bruised  and  torn 
from  its  tibial  attachment.  It  may  be  noted  in  connec- 
tion with  the  causation  of  the  lesion,  that  in  flexion 
and  extension  the  two  cartilages  move  with  the  tibia 
upon  the  femur,  but  in  the  rotation  movements  of  the 
leg  one  or  other  disc  is  fixed  and  the  tibia  rotates  beneath 
them.  Dr.  Scott  Lang  has  pointed  out  that  displace- 
ment of  the  internal  disc  occurs  through  violence  applied 
when  the  leg  is  rotated  outwards,  while  displacement 
of  the  external  cartilage  can  only  occur  when  the  leg 
is  rotated  inwards.  "  Rotation  outwards  is  performed 
chiefly  by  the  biceps  ;  consequently,  when  this  move- 
ment is  taking  place,  the  tibia  will  be  found  to  be  held 
closely  to  the  external  condyle  of  the  femur,  and  the 
outer  cartilage  is  thus  held  firmly  in  its  place  between 
the  two  bones.  But  the  gap  between  the  internal  con- 
dyle and  the  tibia  will  be  increased,  and  the  movable 
cartilage  is  apt  to  slip  between  the  internal  condyle 
and  the  corresponding  part  of  the  tibia.  When  the 
tibia  is  rotated  inwards  the  internal  cartilage  is  held  in 
like  manner  between  the  bones  by  the  internal  rotators, 
while  the  gap  between  the  external  condyle  and  the  tibia 
is  increased "  (Scott  Lang).    The  external  cartilage  is 


480  Surgical  Applied  Anatomy.    [Chap. xxi. 

smaller  than  the  internal,  is  rounder,  is  more  movable, 
and  possibly  on  these  accounts  is  less  likely  to  be 
"  nipped  "  between  the  bones.  It  is  attached  in  part  to 
the  femur  through  the  posterior  crucial  ligament,  and 
is  grooved  by  the  tendon  of  the  popliteus,  two  factors 
which  add  to  its  security. 

Oeiiiwvsiigum,  or  knock-knee. — The  appearances 
produced  by  this  affection  are  familiar.  When  a  person 
stands  erect,  the  feet  together,  the  tibiae  are  practically 
vertical,  and  the  femora  meet  them  at  a  certain  angle. 
The  degree  of  this  angle  depends,  in  normal  subjects,  to 
a  great  extent  upon  the  relative  width  of  the  pelvis. 
In  genu-valgum  the  tibiae  cease  to  be  vertical  in  the 
erect  position  ;  their  lower  ends  deviate  more  and  more 
from  the  middle  line,  until  the  distance  between  the 
two  malleoli  becomes  considerable  when  the  individual 
stands  upright  and  when  he  is  not  concealing  any  of 
the  deformity  by  rotating  the  limb. 

The  progress  of  the  genu-valgum  may  be  divided  into 
three  stages.  In  the  first  stage  there  is  a  yielding  or 
elongation  of  the  internal  lateral  ligament,  and  of  the 
fascial  structures  on  the  inner  side  of  the  joint.  That 
the  yielding  of  this  ligament  alone  will  permit  of  a 
lateral  movement  at  the  articulation  being  accomplished 
is  illustrated  by  cases  of  sprains  of  the  knee,  where  the 
ligament  has  been  torn,  and  where  much  lateral  bend- 
ing has  been  in  consequence  permitted.  It  is  prob- 
able that  the  crucial  ligaments  yield  also  a  little,  and  it 
is  upon  the  posterior  band  attached  to  the  internal  con- 
dyle that  the  strain  possibly  first  comes.  In  the  second 
stage  there  is  a  contraction  of  the  tissues  on  the  outer 
side  of  the  joint  that  have  been  relaxed  by  the  new 
position  of  the  limb.  These  structures  are  the  ilio- 
tibial  band  of  the  fascia  lata,  the  external  lateral  liga- 
ment, and  the  biceps  tendon.  This  contraction  tends 
to  give  permanency  to  the  deformity.  In  the  third 
stage  the  bones  become  changed.  On  the  outer  side 
of  the  joint  the  external  condyle  and  the  outer  tuber- 
osity of  the  tibia  are  pressed  together,  and  through  these 
boc  bs  the  greater  part  of  the  weight  of  the  body  will 


chap.  xxi. j     The  Region  of  the  Knee. 


481 


be  transmitted.  As  a  result  of  the  continual  pressure 
the  parts  waste  a  little,  and  by  their  atrophy  contribute 
not  only  to  the  extent  of  the  deformity  but  also  to  its 
permanency.  On  the  inner  side  the  internal  condyle 
tends  to  become  separated  from  the  tibia,  and  an  in- 
terval to  develop  between  the  two  bones  as  the  deformity 
advances.  This  interval  is  prevented  from  actually 
existing  by  the  development  of  the  condyle,  which 
enlarges,  and  so  still  maintains  its  contact  with  the 
tibia.     Mikulicz  lias  pointed  out  that  '*  the  alteration 


Fig.  63.— a,  Normal  femur ;  B,  femur  in  au  advanced  case  of  knock-knee, 
sliowiug  the  enlargement  of  the  internal  condyle.  The  dotted  line 
in  each  case  represents  the  liue  of  the  epiphysis. 

in  length  on  the  inner  side  of  the  femur  arises  not  from 
alteration  of  the  epiphysis,  but  is  confined  to  the  lowest 
part  of  the  diaphysis."  This  is  shown  in  the  diagram 
(Fig.  63),  where  it  will  be  seen  that  the  enlargement 
of  the  internal  condyle  is  due  almost  entirely  to  increased 
growth  in  the  diaphysis.  The  increased  growth  does 
not  affect  the  anteroposterior  diameter  of  the  condyles. 
Hence,  when  the  knee  is  flexed,  all  trace  of  the  deformity 
disappears. 

The  patella* — Fractures. — This  bone  is  more 
often  broken  by  muscular  violence  than  is  any  other 
in  the  body.  Although  the  patella  may  be  fractured 
by  both  muscular  and  direct  violence,  it  would  appear 
that  the  former  is  the  agent  that  most  often  produces 


482 


Surgical  Applied  Anatomy.   [Chap,  xxi 


the  lesion.  Thus,  in  127  cases  of  simple  transverse 
fracture  collected  by  Hamilton,  he  considers  that 
muscular  action  was  the  cause  of  the  injury  in  106 
instances.  The  form  of  fracture  due  to  muscular  violence 
is  very  uniform.  It  is  nearly  always  transverse,  simple, 
and  through  the  centre  of  the  bone,  or  just  above  that 
point  or  just  below  it.  Fractures  due  to  direct  violence 
may  present  the  same  appearance,  but  they  are  more 
often  starred,  or  oblique,  or  even  longitudinal.  Ex- 
periments upon  the  cadaver  show  that  a  simple  trans- 
verse fracture  about  the  centre  of  the  bone  cannot  be 

produced  with  any  degree  of 
certainty  by  a  direct  blow.  The 
position  of  the  knee  that  most 
favours  fracture  by  muscular 
action  is  that  of  flexion.  When 
the  knee  is  bent,  the  patella 
rests  upon  the  femoral  condyles 
along  its  transverse  axis  only. 
Nearly  the  whole  of  its  upper 
half  is  unsupported  behind, 
and  the  extensor  muscle  acts 
in  a  line  nearly  at  right  angles 
to  the  vertical  axis  of  the  bone. 
Thus,  by  violent  contraction  of 
the  quadriceps,  the  patella  may 
be  snapped  across  the  condyle 
as -a  stick  is  snapped  across  the  knee  (Fig.  64).  As  the 
fracture  usually  causes  the  patient  to  fall,  it  has  been 
supposed  that  the  contact  with  the  ground,  rather  than 
any  previous  muscular  action,  may  have  caused  the 
lesion.  But,  as  Hamilton  has  pointed  out,  if  a  person 
falls  upon  the  bent  knee  when  the  limb  also  is  flexed 
upon  the  trunk,  the  part  that  comes  in  contact  with 
the  ground  is  not  the  patella,  but  the  tubercle  of  the 
tibia. 

In  the  great  majority  of  cases  the  lesion  not  only 
involves  the  bone  but  also  the  cartilage  and  fibrous 
structures  that  cover  it  respectively  behind  and  in 
front ;    the  synovial    membrane  also  is  torn,  and   the 


Tig.  64. —Diagram  to  show 
Mechanism  of  Fracture  of 
the  Patella  hy  rnusculai? 
action. 

a,  Line  of  action  of  quadriceps 
muscle  ;  6.  femur  ;  c,  tibia. 


Chap,  xxi.i     The  Region  of  THE  Knee.  483 

patellar  bursa  opened  up.  Tims  the  synovial  contents 
may  come  in  actual  contact  with  the  skin.  "  It  is 
anatomically  possible,  if  the  fracture  involve  only  the 
lower  and  non-articular  portion  of  the  patella,  and  if 
the  amount  of  the  separation  of  fragments  is  slight, 
that  the  fatty  tissue  behind  the  apex  of  the  patella, 
over  which  the  synovial  membrane  is  reflected,  may 
save  the  latter  from  injury  "  (Henry  Morris).  Jn  all 
cases  where  there  is  much  separation  of  the  fragments, 
the  fibrous  expansion  attached  to  either  side  of  the 
patella  must  be  torn  through.  Indeed,  none  but  a 
slight  separation  of  the  parts  is  possible  until  that  ex- 
pansion is  ruptured.  Braune  has  demonstrated  this 
by  experiment,  by  sawing  through  the  patella  without 
damage  to  the  lateral  ligamentous  structures,  and 
noting  that  but  trifling  separation  of  the  fragments 
was  possible  until  these  structures  had  been  divided. 
In  stellate  fractures,  due  to  direct  violence,  these 
fibrous  expansions  from  the  extensor  tendon  may  be 
uninjured,  and  no  separation  of  any  magnitude  be 
permitted  between  the  portions  of  the  broken  bone. 

The  patella  is  more  readily  broken  by  muscular 
violence  than  is  either  the  extensor  tendon  or  the  liga- 
mentum  patella?.  In  the  flexed  position  it  will  be  seen 
(Fig.  64)  that  the  bone  is  placed  at  a  considerable 
disadvantage  when  compared  with  the  two  other 
structures.  Richet  reports  a  case  where  violent  con- 
traction of  the  quadriceps  caused  the  tubercle  of  the 
tibia  to  be  torn  away  from  the  bone  without  any  other 
lesion  of  the  parts  immediately  concerned  being 
produced. 

The  patella  may  be  congenitally  absent.  It  is 
developed  in  the  tendon  of  the  quadriceps,  remaining 
cartilaginous  until  the  end  of  the  second  year.  Its 
sesamoid  nature  is  seen  in  the  tendency  to  unite  by 
fibrous  rather  than  by  bony  union  after  fracture.  It 
receives  its  blood  supply  from  nearly  all  the  arteries 
round  the  knee-joint. 

Dislocation  of  the  patella. — This  bone  may 
be  dislocated  outwards  or  inwards,  or  turned  upon  its 


4§4 


Surgical  Applied  Anatomy.  [Chap.  xxi. 


c-# 


edge  so  that  its  anterior  and  posterior  surfaces  are 
placed  laterally.  The  luxation  outwards  is  by  far  the 
most  common.  This  depends  upon  the  fact  that  the 
quadriceps,  the  patella,  and  the  ligamentum  patellae  do 
not,  when  the  muscle  is  contracted,  follow  the  lines  of 
the   femur   and   tibia.      They   are    more    nearly   in  a 

straight    line,   that 
a.  passes  to  the  outer 

side  of  the  angle 
formed  by  the 
femur  with  the  leg 
at  the  knee-joint. 
Muscular  contrac- 
tion, therefore, 
tends  to  draw  the 
knee-cap  outwards, 
a  tendency  that  is 
in  all  normal  cir- 
cumstances cor- 
rected by  the  in- 
creased prominence 
of  the  external 
condyle.  The  vastus 
externus  also  is  said 
to  be  more  powerful 
than  the  internus. 

Dislocations  of 
this  bone  are  usually 
due  to  muscular 
action,  and  are  most 
apt  to  occur  in  the 
extended  position 
of  the  limb,  the  position  in  which  the  patella  is  not  fixed 
and  its  ligament  and  the  anterior  part  of  the  joint  cap- 
sule attached  to  the  bone  are  the  most  lax.  The  lateral 
luxations  are  usually  incomplete,  but  may  be  complete. 
In  the  former  case  the  anterior  part  of  the  capsule  need 
not  be  torn,  but  in  the  latter  form  it  can  scarcely  escape 
extensive  rupture. 

In  the  dislocation  of  the  patella  upon  its  edge,  the 


Fig.  65.  —Transverse  Section  of  left  Knee- 
joint  through  the  centre  of  the  Patella 
(Braune). 

a,  Bursa  patel  las;  &,  internal  lateral  ligament  and 
iDner  condyle;  c.  external  lateral  ligament 
and  outer  condyle;  d,  biceps:  e,  semimem- 
branosus; /.  semltendinosus ;  gr,  gracilis 
tendon;  h.  sartoiius;  1,  internal  popliteal 
nerve;  2,  external  popliteal  nerve  ;  3,  inter- 
nal saphenous  vein. 


Chap,  xxi.]     The  Region  of  the  Knee.  485 

inner  border  of  the  bone  usually  projects  forwards, 
while  the  outer  is  placed  between  the  condyles.  But 
little  is  known  as  to  the  mechanism  of  this  dislocation. 

In  dislocations  oi"  the  knee,  which  are  very- 
rare,  the  tibia  may  be  displaced  outwards,  inwards, 
forwards,  or  backwards.  The  two  lateral  luxations 
appear  to  be  more  common  than  the  antero-posterior. 
The  former  are  nearly  always  partial,  the  latter  usually 
complete.  Considerable  violence  is  required  to  produce 
these  luxations,  owing  to  the  great  strength  of  the 
ligaments  and  the  great  width  of  the  bones  involved. 
Direct  violence  to  the  tibia  or  femur,  associated  often 
with  a  twisting  of  the  former  bone,  is  the  common 
cause  of  the  lesion.  It  is  probable  that  in  all  luxa- 
tions of  the  knee  the  crucial  ligaments  are  torn.  The 
lateral  ligaments  also  are  usually  ruptured,  but  in  the 
partial  luxations  they  may  be  sometimes  found  to  be 
intact.  The  tendinous  expansion  of  the  vasti  in  front 
of  the  knee  seldom  escapes  some  laceration,  even  in 
the  partial  dislocations.  The  projection  of  the  spine 
of  the  tibia  between  the  femoral  condyles  offers  an 
obstruction  to  lateral  luxation.  In  the  antero-posterior 
displacements,  the  tibia  is  more  often  luxated  forwards 
than  backwards.  In  these  injuries,  not  only  arc  the 
crucial  and  lateral  ligaments  torn,  together  with  the 
anterior  part  of  the  capsule,  but  the  posterior  ligament, 
the  gastrocnemius,  the  biceps,  and  less  often  the  semi- 
membranosus, suffer  more  or  less  extensive  laceration. 
The  popliteal  vessels  and  nerves  are  much  eompressed, 
and  appear  to  be  more  severely  injured  by  the  femur 
in  the  forward  dislocation  than  by  the  tibia  in  the  back- 
ward displacement. 

The  lower  end  ct  the  femur. — The  condylar 
part  of  the  femur  is  composed  almost  wholly  of  can- 
cellous bone,  but  with  a  slight  layer  of  compact  tissue. 
It  is  so  spongy  that  it  may  be  pierced  by  a  bullet,  as 
pointed  out  by  Legouest,  without  any  splintering  of 
the  bone  being  produced  and  without  damage  to  the 
articulation.  The  fractures  that  may  be  met  with  in 
the  lower  end  of  the  bone  are  the  following:    (1)    A 


486  Surgical  Applied  Anatomy.   [Chap.  xxi. 

fracture  of  the  shaft  above  the  condyles  ;  (2)  a  sepa- 
ration of  the  lower  epiphysis  ;  (3)  a  fracture  separating 
either  the  outer  or  inner  condyle ;  (4)  a  T-shaped 
fracture,  i.e.,  a  transverse  fracture  above  the  condyles 
with  a  vertical  one  between  those  processes.  These 
lesions  are,  as  a  rule,  due  to  well  localised  direct  violence. 
Fractures  Nos.  1  and  4  may  be  produced  by  indirect 
violence,  as  by  a  fall  upon  the  feet  from  a  height.  Henry 
Morris  states  that  lateral  flexion,  or  force  applied  in  a 
lateral  direction,  is  best  calculated  to  produce  a  separation 
of  the  epiphysis.  Hamilton  reports  a  strange  case  in  a 
man  aged  21,  whose  outer  condyle  was  fractured  by 
the  twist  of  the  leg,  which  happened  while  he  was  un- 
dressing himself  to  bathe.  The  only  fracture  that 
requires  special  notice  in  this  place  is  the  fracture  of  the 
shaft  just  above  the  condyles.  The  lesion  is  situated 
generally  about  2  inches  above  the  line  of  the  epiphysis, 
and  corresponds  to  the  spot  where  the  compact  shaft 
joins  the  softer  and  more  cancellous  tissue  of  the  lower 
end  of  the  bone.  It  is  near  the  place,  also,  where  the 
femoral  artery  crosses  the  bone  to  reach  the  ham,  and 
it  has  thus  happened  that  the  vessel  has  been  wounded 
by  splinters  in  this  particular  injury.  The  fracture  is 
usually  oblique,  from  behind,  downwards  and  forwards. 
The  lower  fragment  will  be  drawn  upwards  by  the  same 
muscles  that  produce  shortening  in  other  fractures  of 
the  shaft  (page  462),  and  its  sharp  upper  end  is  very 
apt  to  be  pulled  forcibly  into  the  popliteal  space  by  the 
gastrocnemius  muscle.  This  latter  displacement  is 
difficult  to  remedy.  If  the  limb  be  extended,  the  frag- 
ment is  only  drawn  the  more  into  the  ham,  and  it  is 
therefore  possible  for  the  limb  to  appear  straight  and 
yet  have  the  knee-joint  much  bent.  In  several  cases 
of  this  injury  I  divided  the  tendo  Achillis,  and 
then  placed  the  limb  upon  a  straight  splint,  following  a 
practice  suggested  by  Mr.  Bryant.  The  effect  upon 
the  position  of  the  fragments  was  in  each  case  very  good 
{Brit.  Med.  Jour.,  1883).  The  lower  fragment  of  the 
femur  may  be  replaced  by  completely  flexing  the  leg 
on  the  thigh.    (Hutchinson  and  Barnard.) 


Chap,  xxi.)      The  Region  of  the  Knee.  487 

The  upper  end  of  the  tibia  is  sometimes  the 
seat  of  fracture,  although  of  all  parts  of  this  bone  the 
upper  third  is  the  part  least  often  broken.     One  or 
other  of  the  tuberosities  may  be  broken  off,  or  there 
may  be  a  transverse  or  oblique  fracture  of  the  upper 
end  of  the  shaft  associated  with  a  vertical  one  running 
up  into  the  joint  between  the  two  tuberosities.     Such 
accidents  are  the  result,  in  nearly  every  instance,  of 
great  direct  violence.     Dr.  Hutton  reports  a  case,  prob- 
ably  unique,  in  which  the  spine  of  the  tibia,  the  central 
part  of  the  head  of  the  bone,  and  a  considerable  portion 
of  the  left  articular  surface  were  torn  from  the  rest 
of  the  tibia.     The  anterior  crucial  ligament  was  attached 
to    the    fragment.     The    patient    had    been    wrestling 
while  in  a  state  of  intoxication,  and  had  been  heavily 
thrown .     Madame  Lachapelle  reports  a  case  of  separation 
of  the  upper  epiphysis  of  the  tibia  caused  by  traction 
during  parturition  ;  but  I  am  not  aware  of  any  reported 
case  of  separation  of  this  epiphysis  due  to  violence  or 
under  circumstances  other  than  these. 

The  spongy  tissue  in  the  head  of  this  bone  and  in 
the  lower  end  of  the  femur  is,  par  excellence,  the 
favourite  seat  for  myeloid  sarcomata. 

In  exeising  the  knee-joint  through  an  incision 
commencing  at  the  back  of  one  condyle,  and  continued 
across  the  joint,  just  below  the  patella,  to  the  back 
of  the  other  condyle  the  following  structures  are 
divided  :  Skin,  fascia,  patellar  plexus  of  nerves  (formed 
by  the  middle  and  internal  cutaneous  and  the  patellar 
branch  of  the  long  saphenous),  bursa  patellae,  anterior 
part  of  the  capsule,  ligamentum  patellae,  synovial  mem- 
brane, lateral  and  crucial  ligaments,  the  superior  and 
interior  articular  arteries,  the  anastomotica  magna, 
and  the  anterior  tibial  recurrent  vessels. 

The  incision  over  the  inner  condyle  need  not  be 
made  so  far  back  as  to  divide  the  internal  saphenous 
vein  and  nerve.  In  sawing  the  femur  it  is  most 
important  that  the  exact  inclination  of  the  joint 
surface  of  the  bone  be  reproduced.  If  improperly  sawn 
the  patient  would  be  bow-legged  or  knock-kneed.    The 


488 


Surgical  Applied  Anatomy.    [Chap.  xxi. 


rule,  therefore,  is  that  the   saw  be  applied  parallel  to 
the  articular  surface  and  perpendicular  to  the  shaft. 

In  young  subjects  care  must  be  taken  that  the 
saw-cuts  do  not  pass  beyond  the  epiphyseal  line.  The 
upper  limit  of  the  femoral  epiphysis  will  be  represented 
by  a  horizontal  line  drawn  across  the  bone  at  the  level 
of  the  tubercle  for  the  adductor  magnus.     If  the  whole 

of  the  trochlear  surface 
be  removed  in  the  ex- 
cision the  whole  of  the 
epiphysis  will  have  been 
taken  away.  A  single 
nucleus  appears  in  this 
epiphysis  shortly  before 
birth,  and  joins  the 
shaft  about  the  twen- 
tieth year.  The  limits 
to  the  tibial  epiphysis 
are  represented  behind 
and  at  the  sides  by  a 
horizontal  line  that  just 
marks  off  the  tuberosi- 
ties. It  includes,  there- 
fore, the  depression  for 
the  insertion  of  the 
semimembranosus,  and 
also  the  facet  for  the 
fibula.  In  front  the 
epiphyseal  line  slopes 
downwards  on  either 
side  to  a  point  on  the 
upper  end  of  the  shin, 
so  as  to  enclose  the  whole  of  the  tubercle  of  the  tibia. 
The  centre  joins  the  main  bone  at  the  twenty-first 
or  twenty-second  year.  The  popliteal  artery  runs 
some  risk  of  being  wounded  in  excision  of  the 
joint.  The  vessel  is  separated  by  some  little  distance 
from  the  popliteal  surface  of  the  femur  (Fig.  66),  but 
is  in  very  close  relation  to  the  tibia,  the  posterior  liga- 
ment alone  intervening  at  the  upper  level  of  the  bone. 


Fig.  66.  —Disarticulation  at  the  Knee- 
joint  by'  single  Anterior  Flap 
lAgatz). 

a,  Int.  condyle  ;  b,  ext.  condyle  ;  c,  inter- 
condyloid  fossa  ;  d,  lig.  patellae  ;  e,  sar- 
torius;/,  gracilis;  y,  semitendinosus; 
h,  ext.  lat.  ligament;  i,  popliteus ;  j, 
plantaris  ;  k,  semimembranosus  ;  I  and 
in,  inner  head  of  gastrocnemius ;  n,  outer 
head  of  gastrocnemius;  o,  biceps;  p, 
popliteal  vessels;  q,  int.  pop.  nerve. 


Chap,  xxi.]     The  Region  of  the  Knee.  489 

It  thus  happens  that  the  risk  of  wounding  the  artery 
is  greater  when  the  tibia  is  sawn  than  when  the  lower 
part  of  the  femur  is  being  removed. 

Excision  of  the  knee  is,  to  a  large  extent,  replaced 
by  arthrectonry.  Indeed,  excision  of  this  joint  carried 
out  in  the  complete  manner  just  described  must  be 
classed  as  a  quite  rare  operation. 

Amputation  throug-li  the  knee-joint. — To 
illustrate  the  anatomy  of  the  part  an  amputation  by 
a  single  anterior  flap  may  be  selected.  In  fashioning 
the  anterior  flap  (which  is  composed  only  of  integument), 
and  in  opening  the  joint,  the  patellar  plexus  of  nerves, 
the  superficial  branches  of  the  plexus  of  arteries,  the 
ligamentum  patellae,  and  the  anterior  part  of  the  capsule 
will  be  cut.  Nearer  the  condyles  of  the  femur  the 
anastomotic  and  the  two  superior  articular  arteries 
will  be  divided.  The  long  saphenous  vein  and  nerve 
will  be  divided  at  the  inner  angle  of  the  flap.  On  the 
cut  surface  made  by  the  posterior  incision  will  be  found 
divided  the  sartorius,  gracilis,  and  semitendinosus,  the 
semimembranous,  both  heads  of  the  gastrocnemius, 
the  popiiteus,  plantaris,  and  biceps.  The  popliteal 
vessels,  the  sural  arteries,  the  short  saphenous  vein, 
(lie  internal  and  external  popliteal  nerves,  the  external 
saphenous  and  the  small  sciatic  nerves  will  also  be  found 
divided  in  the  same  incision. 

The  most  convenient  amputation  at  the  knee-joint 
is  by  equal  lateral  flaps  (Stephen  Smith's  operation). 
This  operation  has  been  attended  by  excellent  results, 
and  in  actual  practice  the  method  of  amputation  by  a 
single  anterior  flap  is  but  very  rarely  employed. 


CHAPTER  XXII. 

THE   LEG. 


Surface   anatomy— The  anterior  border  of  the 

tibia  can  be  felt  in  its  entire  length,  forming,  as  it  does, 
the  prominence  of  the  shin.    It  should  be  remembered 


49°  Surgical  Applied  Anatomy.  [Chap.  xxii. 

that  this  border  presents  a  somewhat  flexuous  course, 
being  curved  outwards  above  and  inwards  below.  The 
broad  internal  surface  of  the  bone  is  subcutaneous, 
and  the  internal  border  can  be  followed  from  the 
tuberosity  to  the  malleolus.  The  head  of  the  fibula 
can  be  distinctly  made  out,  but  the  upper  half  of  the 
shaft  of  the  bone  is  lost  beneath  the  mass  of  muscle 
on  the  outer  side  of  the  limb.  The  lower  half  of  the 
fibular  shaft  can  be  felt,  and  the  bone  just  above  the 
malleolus  becomes  subcutaneous  in  the  interval  between 
the  peroneus  tertius  and  the  two  other  peroneal  tendons. 
The  fibula  is  situated  so  far  behind  the  line  of  the  tibia 
that  a  knife  thrust  transversely  through  the  leg  from 
the  inner  side  behind  the  tibia  will  appear  in  front 
of  the  fibula  on  the  outer  side  (Fig.  68).  Between  the 
tibia  and  fibula  the  outline  of  the  tibialis  anticus  muscle 
can  be  well  defined  when  it  is  in  action.  To  its  outer 
side  is  the  less  conspicuous  and  narrower  eminence 
formed  by  the  extensor  communis  digitorum.  In 
well-developed  limbs  the  groove  that  separates  these 
two  muscles  is  very  distinct,  and  forms  the  best  guide 
to  the  anterior  tibial  artery.  In  the  lower  third  of 
the  leg  these  muscles  become  tendinous,  and  between 
them  the  extensor  longus  pollicis  can  be  felt  as  it  comes 
to  the  surface.  The  long  and  short  peroneal  muscles 
can  be  defined,  and  their  tendons  followed  behind  the 
malleolus.  When  in  active  contraction  the  interval 
between  the  two  muscles  is  often  well  marked.  The 
gastrocnemius  muscle  and  the  more  superficial  parts 
of  the  soleus  are  brought  well  into  view  when  the  body 
is  raised  upon  the  toes.  The  two  heads  of  the  former 
muscle  are  then  quite  conspicuous,  and  it  can  be  seen 
that  the  inner  head  is  the  larger  and  descends  lower 
in  the  leg. 

The  popliteal  artery  bifurcates  on  a  level  with  the 
lower  part  of  the  tubercle  of  the  tibia.  The  course  of 
the  posterior  tibial  vessel  is  represented  by  a  line  drawn 
from  the  middle  of  the  limb  at  the  lower  part  of  the 
ham  to  a  spot  midway  between  the  inner  malleolus 
and  the  prominence  of  the  heel.     The  artery  becomes 


Chap.  XXII.]  l^HE   LEG.  49 1 

superficial  in  the  lower  fourth  of  the  leg,  where  it  may 
be  felt  pulsating  between  the  tendo  Achillis  and  the 
tibia.  The  peroneal  artery  arises  about  3  inches  below 
the  knee,  follows  the  posterior  surface  of  the  fibula, 
and  ends  behind  the  outer  malleolus.  The  position 
of  the  anterior  tibial  artery  may  be  indicated  by  a  line 
drawn  from  a  point  midway  between  the  outer  tuberosity 
of  the  tibia  and  the  head  of  the  fibula  to  the  centre  of 
the  front  of  the  ankle-joint.  Both  the  saphenous  veins 
can  often  be  made  out  in  the  leg.  The  inner  or  larger 
vein  passes  in  front  of  the  malleolus  and  ascends  just 
behind  the  internal  border  of  the  tibia.  With  it  runs 
the  long  saphenous  nerve.  The  short  saphenous  vein 
lies  behind  the  outer  malleolus,  and  passing  up  the 
middle  of  the  calf  ends  at  the  ham.  It  is  accompanied 
by  the  external  saphenous  nerve. 

The  leg. — The  skin  is  somewhat  more  adherent  to 
deeper  parts  in  the  leg  than  it  is  in  the  thigh.  The 
difference  in  the  degree  of  this  adhesion  is  obvious 
when  skin-flaps  are  dissected  up  from  the  two  parts 
in  cases  of  amputation.  Over  the  internal  surface  of 
the  tibia  and  the  greater  part  of  the  shin,  the  integu- 
ment lies  directly  upon  the  periosteum  and  bone,  nothing 
intervening  save  a  scanty  amount  of  subcutaneous 
fascia.  Thus  blows  and  kicks  over  these  parts  of  the 
leg  are  apt  to  be  associated  not  only  with  much  pain 
but  also  with  much  bruising  or  tearing  of  the  integu- 
ment. A  "  graze  on  the  shin  "  is  one  of  the  commonest 
of  lesions,  and  is  produced  by  a  degree  of  violence  that 
upon  a  well-covered  part  would  have  little  or  no  effect. 
It  will  be  understood  that  ulcers  over  these  feebly 
protected  parts  may,  if  they  spread  in  depth,  readily 
expose  the  bone  and  lead  to  some  disease  of  its  substance, 
or  to  at  least  some  inflammation  of  its  periosteum. 
Scars  left  by  deep  ulcers  or  burns  are  also  often  found 
to  be  quite  adherent  to  the  bone. 

The  aponeurosis  of  the  leg  invests  it  like  a 
tightly-drawn  buskin,  being  lacking  only  over  the 
subcutaneous  surfaces  of  the  bones.  It  is  attached 
to  the  head  and  the  anterior  and  inner  borders  of  the 


492  Surgical  Applied  Anatomy,  tchap.  xxit. 

tibia,  the  head  of  the  fibula,  and  the  two  malleoli.  It 
is  continuous  above  with  the  fascia  lata,  and  below 
with  the  fascia  of  the  foot  and  the  annular  ligaments. 
It  is  thicker  in  front  than  behind,  and  is  especially  thick 
at  the  upper  part  of  the  leg  just  below  the  knee.  Here 
the  fascia  offers  great  resistance  to  the  growth  of  tumours 
springing  from  the  head  of  the  tibia.  From  the  deep 
surface  of  the  aponeurosis  two  septa  pass  inwards  to 
be  attached  to  the  anterior  and  external  borders  of  the 
fibula.  They  serve  to  isolate  the  two  larger  peroneal 
muscles  from  the  other  muscles  of  the  limb,  and  form  a 
closed  space  which  might  form  a  definite  and  well 
localised  cavity  for  pus.  Beneath  the  gastrocnemius 
and  soleus  a  layer  of  fascia  extends  between  the  two 
bones  and  covers  in  the  deep  layer  of  muscles.  It  is 
thin  above  but  denser  below,  and  would  have  some 
influence  in  directing  the  progress  of  a  deep  abscess. 

In  the  upper  third  of  the  leg  there  is  a  septum  between 
the  tibialis  anticus  and  extensor  communis  digitorum, 
which  must  be  found  in  the  operation  for  ligaturing 
the  upper  part  of  the  anterior  tibial  artery.  I  have 
never  had  the  good  fortune  to  see  the  very  distinct 
"  white  line  "  that  many  text-books  describe  as  indicating 
the  position  of  this  septum. 

In  the  substance  of  the  soleus  muscle  there  is  a 
tendinous  expansion  connected  with  the  border  of  the 
tibia,  that  runs  backwards  and  towards  the  middle 
line.  In  cutting  through  the  soleus  to  apply  a  ligature 
to  the  posterior  tibial  artery,  this  intersection  may  be 
mistaken  for  the  aponeurosis  on  the  deep  surface  of 
the  muscle. 

Several  cases  are  reported  of  rupture  of  some  part 
of  the  gastrocnemius  muscle  during  violent  exertion. 
The  tendo  Achillis  has  been  ruptured  under  like  cir- 
cumstances. It  is  said  that  the  plantaris  tendon  is 
also  not  unfrequently  torn  across,  producing  a  sudden 
sharps  pain  in  the  calf  during  exertion,  to  which  the 
French  give  the  name  "  coup  de  fouet." 

Vessels. — The  large  arteries  of  the  leg,  being  all 
in  close^proximity  with  the  bones,  are  apt  to  be  injured 


chap.  xxn. i  TtiE  Le&  493 

by  sharp  fragments  in  fractures  of  the  limb.  This 
especially  applies  to  the  peroneal  artery,  which  runs 
along  the  fibula  in  a  fibrous  canal,  and  is  in  considerable 
risk  of  being  wounded  in  fractures  about  the  middle 
of  that  bone.  It  is  at  the  point  of  bifurcation  of  the 
popliteal  artery  that  emboli  are  peculiarly  apt  to  lodge. 
They  plug  the  vessel  and  practically  block  the  three 
main  arteries  of  the  leg.  Gangrene,  therefore,  not 
unfrequently  follows  the  occurrence.  Billroth  states 
that  in  all  the  cases  of  gangrene  of  the  leg  due  to 
embolism  that  he  has  met  with,  the  plug  was  found 
situated  at  the  bifurcation  of  the  popliteal  trunk  ("  Clinical 
Surgery,"  1881).  According  to  some  French  surgeons, 
aneurism  of  the  commencement  of  the  posterior  tibial 
artery  is  more  often  associated  with  gangrene  of  the 
leg  than  is  a  popliteal  aneurism.  The  reason  they  assign 
is  the  following  :  The  aneurism  on  the  former  vessel 
not  only  interferes  with  the  passage  of  the  blood  into 
the  posterior  tibial  and  'peroneal  arteries,  but  also 
compresses  the  anterior  tibial  vessel  and  with  it  the 
anterior  tibial  recurrent,  an  artery  that  is  of  so  great 
importance  in  establishing  the  collateral  circulation. 

Varicose  veins  are  more  commonly  met  with  in 
the  leg  than  in  any  other  part  of  the  body,  save,  perhaps, 
in  the  hamiorrhoidal  and  spermatic  veins.  This  depends 
upon  the  great  length  of  the  veins  of  the  lower  limb, 
the  large  columns  of  blood  their  valves  have  to  support, 
their  vertical  position,  the  liability  of  the  great  trunks 
(iliac),  into  which  they  ultimately  enter,  to  be  com- 
pressed, and  upon  the  fact  that  the  superficial  veins, 
being  outside  the  fascia,  lose  that  assistance  to  the 
circulation  derived  from  muscular  contraction.  From 
a  physical  point  of  view  the  vascular  system  must  be 
regarded  as  a  vertical  column  of  fluid.  The  lower  the 
level  the  greater  is  the  pressure  on  the  containing  walls. 
The  saphenous  veins  are  thin-walled,  distensible  tubes 
situated  outside  the  rigid-walled  cylinder  formed  by 
the  deep  fascia  of  the  leg  and  thigh,  low  in  the  body, 
where  the  pressure  from  gravity  is  great*  st  (Hill).  The 
use  of  garters  especially  affects  the  long  saphenous  vein, 


494  Surgical  Applied  AnaTomV.  [Chap.XXtl. 

which  lies  close  to  the  bone  at  the  spot  about  which  these 
contracting  bands  are  usually  applied.  Between  the 
two  layers  of  the  muscles  of  the  calf  Verneuil  describes 
a  venous  plexus,  which  he  believes  to  be  more  often 
the  seat  of  varices  than  are  the  vessels  of  the  surface. 
A  varicose  condition  of  these  deeply  placed  veins  may  ex- 
plain the  "  aching  legs  "  complained  of  by  those  who  stand 
a  great  deal.  The  intramuscular  veins  are  very  large. 
Callender  showed  that  the  six  chief  veins  which  pass 
from  the  soleus  muscle  alone  to  enter  into  the  posterior 
tibial  and  peroneal  trunks  have  a  united  diameter  of 
not  less  than  1  inch.  Varix  would  appear  to  commence 
most  often  at  points  where  the  deep  veins  join  the  super- 
ficial vessels.  There  is  good  reason  for  this, 
for  at  these  points  three  forces  meet,  the 
general  directions  of  which  are  shown  in 
»  1  the  annexed  diagram  (Fig.  67).     There  is 

the  weight  of  the  superincumbent  column 
of  blocd  (a)  acting  from  above,  the  resistance 
a  r  offered  by  the  next  valve  below  the  point 

of  entry  of  the  deep  vein  acting  from  below 
£  (6),  and  the  force  with  which  the  blood  is 

'Fig.  67.  driven  by  the  contracting  muscles  out  of 
the  deep  vein  into  the  superficial  trunk 
acting  at  an  angle  to  both  these  lines  of  force  (c).  Un- 
fortunately for  the  subjects  of  varices,  the  two  principal 
veins  (the  saphenous)  are  accompanied  by  sensory 
nerves,  and  there  is  no  doubt  that  much  of  the  pain 
incident  to  varicose  veins  in  the  leg  depends  upon 
pressure  on  these  nerves. 

With  reference  to  pain  in  the  leg-,  it  must  be 
remembered  that  the  nerves  that  bring  sensation  to  the 
part  arise  at  a  considerable  distance  from  their  points 
of  termination,  and  that  the  causes  of  pain  in  the  limb 
may  be  situated  far  away  from  the  seat  of  trouble. 
Thus  Sir  B.  Brodie  mentions  the  case  of  a  gentleman 
who  suffered  from  severe  pain  in  the  left  leg,  from  the 
foot  to  the  knee,  in  the  course  of  the  peroneal  nerve. 
No  cause  could  be  found  for  it.  At  the  patient's  death, 
however,  a  large  tumour  was  found  attached  to  the 


Chap,  x  x  1 1 .  i  The  Leg.  a  o 


r;j 


lumbar   spine,    which    had    evidently   compressed    the 
left  great  sciatic  nerve. 

There  would  appear  to  be  little  connection  between 
disease  in  the  rectum  and  a  pain  in  the  leg,  yet  in  one 
case  at  least  that  connection  was  marked.  "  Only 
recently,"  writes  Mr.  Hilton,  "  I  saw  a  gentleman  from 
South  Wales,  who  was  the  subject  of  stricture  of  the 
rectum  from  malignant  disease.  He  suffered  pain  in 
the  kncc-joiiil  and  in  the  back  part  of  the  leg.  This 
led  me  to  suspect,  what  really  turned  out,  upon  careful 
examination,  to  be  the  case,  that  a  large  mass  of  cancer 
was  involving  the  nerves  on  the-  anterior  part  of  the 
sacrum,  and  also,  no  doubt,  the  obturator  nerve." 

Dr.  Ralfe  mentions  cases  of  renal  calculus  attended 
by  severe  pain  in  the  sole  of  the  foot,  and  I  have  met 
with  many  instances  of  this  association,  the  pain  being- 
most  commonly  in  the  heel. 

Fractures  of  the  leg.— Of  the  bones  of  the  leg 
the  tibia  and  fibula  are  more  often  broken  together 
than  singly,  and  of  separate  bones  the  fibula  is  more 
often  fractured  than  is  the  larger  bone. 

1.  The  tibia  and  fibula.  As  regards  the  resistance 
it  offers  to  violence  the  fibula  presents  about  the  same 
degree  of  strength  in  all  its  parts,  save  at  the  malleolus 
and  at  its  upper  extremity.  Its  great  length  and  the 
in  inner  of  its  attachment  to  the  tibia  (its  two  ends 
being  fixed  and  its  main  part  being  unsupported)  render 
it  a  slender  bone,  and  but  for  the  efficient  protection 
it  derives  from  the  thick  pad  of  muscles  that  surrounds 
it,  it  would  no  doubt  be  very  frequently  broken.  This 
is  all  the  more  likely  to  be  the  case,  since  the  bone  is 
placed  upon  the  more  exposed  aspect  of  the  limb. 

The  shaft  of  the  tibia  presents  various  degrees  of 
strength,  according  as  we  regard  its  upper,  middle,  or 
lower  third.  According  to  Dr.  Leriche,  the  average 
transverse  diameter  of  the  adult  tibia  just  below  the 
tubarosities  is  a  little  over  if  inches.  The  transverse 
diameter  at  the  base  of  the  malleolus  is  a  little  less  than 
If  inches,  and  that  of  the  narrowest  part  of  the  bone 
is  a  little  more  than  1  inch.     This  narrow  part  is  at  the 


496  Surgical  Applied  Anatomy,  ichap.  xxii. 

junction  of  the  lower  with  the  middle  third  of  the  shaft, 
and  is  the  weakest  point  in  the  bone. 

The  relation  of  the  compact  to  the  cancellous  tissue 
is  about  the  same  in  all  parts  of  the  shaft ;  but  accord- 
ing to  MM.  Fayel  and  Duret,  the  spongy  tissue  is  arranged 
in  two  independent  vertical  columns,  one  occupying 
the  upper  two-thirds  and  the  other  the  lower  third  of 
the  bone.  The  minimum  of  resistance  (these  authors 
assert)  is  at  the  point  where  these  two  systems 
meet.  Thus  it  happens  that  the  most  common  spot 
for  a  fracture  of  the  tibia  is  at  the  junction  of  the  middle 
with  the  lower  third  of  the  shaft.  It  is  here  that  the 
bone  yields  when  broken  by  indirect  violence,  while  the 
lesions  depending  upon  direct  violence  may  be  at  any 
part  of  the  shaft.  Owing  to  the  thin  covering  of  soft 
parts,  and  the  slight  barrier  interposed  between  the 
fracturing  force  and  the  bone,  it  comes  to  pass  that 
fractures  of  the  leg  are  more  often  compound  and  com- 
minuted than  are  those  of  any  other  bones  of  the  ex- 
tremities. If  the  fracture  be  oblique,  as  is  commonly 
the  case  when  the  violence  is  indirectly  applied,  the  line 
of  breakage  usually  extends  from  behind,  downwards, 
forwards,  and  a  little  inwards.  The  lower  fragment, 
with  the  foot,  is  drawn  up  behind  the  rest  of  the  bone 
by  the  muscles  of  the  calf ^  and  is  usually  displaced  also 
outwards  by  the  obliquity  of  the  fracture  line.  Often 
the  lower  fragment  is  slightly  rotated  outwards  by  the 
rolling  over  of  the  foot,  a  rotation  produced  by  the 
simple  weight  of  the  limb.  If  the  fracture  be  transverse 
there  may  be  little  or  no  displacement.  The  fibula  is 
usually  broken  at  a  higher  level  than  the  tibia,  and  its 
lower  fragment  follows,  of  course,  with  absolute  precision 
the  corresponding  fragment  of  the  larger  bone.  A 
remarkable  spiral  fracture  {fracture  helico'ide),  involving 
the  lower  third  of  the  tibia,  has  been  described  by  French 
surgeons.  It  is  associated  with  a  more  or  less  vertical 
fissure  that  involves  the  ankle-joint,  and  with  a  fracture 
of  the  fibula  high  up.  MM.  Leriche  and  Tillaux  have 
shown  that  this  injury  is  due  to  torsion,  especially  to 
some  twisting  of  the  leg  while  the  foot  is  fixed. 


Chap.  XXII.] 


The  Leg. 


497 


2.  The  fibula  alone.  Fractures  of  this  bone  in 
its  loAver  fourth  are  usually  due  to  indirect  violence, 
and  will  be  dealt  with  in  connection  with  the  ankle- 
joint.    When  it  is  broken  in  any  other'part  the  fractur- 


Fig.  68.  — Amputation  of  Leg  at  junction  of  Upper  with  Middle  Third 
l>y  single  Posterior  Flap  (Agatz). 

o,  Tibia;  b,  fibula;  r,  tibialis anticus :  <>,  ext.  com.  rlii-'it  ;  <•,  peron.  long.;/,  tib. 
post. ;  a,  BOleus  with  flow  Iohk.  digit;  ft,  gastrocnemius :  ?'.  antenoi  tibial 
vessels;  ./,  post.  tii>ial  and  peroneal  vessels;  fc,  int.  saphen.  vein;  /,  post 
tibial  nerve. 


ing  force  is  usually  directly  applied,  the  lesion  transverse, 
and  the  displacement  insignificant,  or  scarcely  obvious. 
The  tibia  acts  as  an  efficient  splint. 

3.  The  tibia  alone.     The  malleolus  may  be  broken 


G 


498 


Surgical  Applied  Anatomy.  [Chap.  xxii. 


by  a  blow,  or  the  lower  epiphysis  separated.  The 
latter  comprises  the  whole  of  the  inner  malleolus  and 
the  facet  with  which  the  fibula  articulates.  It  joins 
the  shaft  during  the  eighteenth  or  nineteenth  year. 
Fractures  of  the  tibia  alone  are  nearly  always  due  to 
direct  violence,  and  whilst  most  common  in  the  lower  third 
of  the  bone,  become  more  rare  as  the  knee  is  approached. 
Whsn  transverse  there  may  bs  no  visible  displacement, 


Fig.  69.— Transverse  Section  through  the  Lower  Third  of  the  Leg 
(Braune). 

a,  Tibialis  an ticus  ;  6,  extensor  longus  pollicis;  c,  extensor  communis  digitorum; 
dx  peroneus  brevis  ;  e,  peroneus  longus ;  /,  tibialis  posticus :  g,  flexor  longus 
digitorum  ;  h,  flexor  longus  pollicis;  i,  gastrocnemius  and  soleus  ;  j,  short 
saphenous  nerve  and  vein  ;  fc,  anterior  tibial  vessels  and  nerve;  I,  peroneal 
vessels;  m,  posterior  tibial  vessels  and  nerve  ;  n,  musculo-cutaneous  nerve. 


the  fibula  acting  as  a  splint..  Thus  Mr.  H.  Morris  men- 
tions the  case  of  a  woman  who  walked  into  and  out  of  a 
hospital  with  a  transverse  fracture  of  the  tibia  that  was 
not  detected  on  examination,  and  was  not  indeed  dis- 
covered until  two  days  after  the  accident.  When  the 
fracture  is  just  above  the  ankle  the  lower  fragment  may 
be  moved  in  whatever  direction  the  foot  is  forced,  such 
displacement  being  resisted  and  limited  by  the  inferior 
tibio-fibular  ligaments. 


Chap,  xxn.]  The  Leg.  499 

In  rickets  the  tibia  is,  of  all  the  bones  of  the 
extremities,  the  one  that  most  frequently  becomes 
bent.  Jt  yields  at  its  weakest  part  (the  lower  third), 
and  there  the  bone  will  be  found  to  have  developed  a 
curve  forwards  and  a  little  outwards. 

Amputation  of  the  leg  at  the  junction  of  the 
upper  with  the  middle  third  by  unequal  antero-posterior 
flaps  may  be  taken  as  an  example.  This  is  not  the  best 
method  of  amputation,  but  it  serves  best  to  illustrate 
the  anatomy  of  the  part.  In  the  anterior  flap  the  follow- 
ing structures  would  be  cut :  Skin,  cutaneous  nerves, 
fascia,  tibialis  anticus,  extensor  communis  digit orum, 
and  a  little  of  the  extensor  proprius  pollicis,  the  pero- 
neus  longus,  and  a  small  part  of  the  upper  extremity 
of  the  peroneus  brevis,  the  anterior  tibial  vessels  and 
nerve,  and  the  musculo-cutaneous  nerve.  In  the 
posterior  flap  the  following  would  be  the  parts  divided  : 
Skin,  external  and  internal  saphenous  veins  and  nerves, 
fascia,  gastrocnemius,  plantaris,  soleus,  tibialis  posticus, 
flexor  longus  digitorum,  a  little  of  the  upper  end  of  the 
flexor  longus  pollicis,  the  posterior  tibial  vessels  and 
nerve,  and  the  peroneal  vessels. 

Fig.  68  shows  the  stump  left  after  the  amputation 
through  the  lower  part  of  the  upper  third  of  the  leg 
by  means  of  a  single  flap  cut  from  the  calf.  It  serves 
to  show  the  relations  of  the  chief  parts  divided,"  and 
gives  a  good  idea  of  the  stump  that  would  be  left  in  an 
amputation  by  an  anterior  skin  flap  and  a  posterior 
transfixion  flap  cut  from  the  calf. 

In  Fig.  69  is  shown  a  transverse  section  of  the  leg 
at  the  lower  third,  from  which  can  be  gathered  an  idea 
of  the  number  and  position  of  the  parts  cut  in  amputa- 
tions through  that  part. 

An  excellent  method  of  amputation  at  the  upper 
part  of  the  leg  is  by  a  single  external  flap  containing  the 
anterior  tibial  artery  in  its  entire  length. 


5°° 
CHAPTER    XXIII. 

THE     ANKLE     AND     FOOT. 

Surface  anatomy. — Bony  points. — The  outlines 
of  the  two  malleoli  can  be  very  distinctly  defined. 
The  external  is  somewhat  the  less  prominent,  descends 
lower,  and  lies  farther  back  than  the  internal  process. 
The  tip  of  the  outer  malleolus  is  about  |-  an  inch  behind 
and  below  the  tip  of  the  corresponding  bony  prominence. 
The  antero-posterior  diameter,  however,  of  the  internal 
malleolus  is  such  that  its  posterior  border  is  on  a  level 
with  that  of  the  outer  process  behind. 

On  the  dorsum  of  the  foot  the  individual  tarsal 
bones  are  not  to  be  distinguished,  although  the  astrag- 
alus forms  a  distinct  projection  upon  that  surface 
when  the  foot  is  fully  extended. 

On  the  inner  side  of  the  foot  the  tuberosity  of  the 
os  calcis  may  be  felt  most  posteriorly.  In  front  of  it, 
and  about  1  inch  vertically  below  the  inner  malleolus, 
is  the  projection  of  the  sustentaculum  tali.  About 
l\  inches  in  front  of  the  malleolus  the  tubercle  of  the 
scaphoid  can  be  distinctly  made  out.  In  the  interval 
between  it  and  the  last-named  process  lies  the  inferior 
calcaneo-scaphoid  ligament,  and  the  tendon  of  the  tibialis 
posticus.  Farther  towards  the  front  of  the  foot  can 
be  felt  the  ridge  formed  by  the  base  of  the  first  meta- 
tarsal bone,  and  between  it  and  the  scaphoid  tubercle 
lies  the  inner  cuneiform  bone.  Lastly,  the  shaft  of  the 
first  metatarsal  bone,  its  expanded  head,  and  the  sesa- 
moid bones  that  lie  on  the  plantar  aspect  of  the  meta- 
tarsal phalangeal  joint  can  be  more  or  less  distinctly 
defined.  On  the  outer  side  of  the  foot  the  external 
surface  of  the  os  calcis  is  subcutaneous  in  nearly  the 
whole  of  its  extent.  Less  than  1  inch  below  and  in  front 
of  the  malleolus  is  the  peroneal  tubercle,  with  the  short 
peroneal  tendon  above  it  and  the  long  one  below  it. 
Some  2|-  inches  from  the  outer  malleolus  the  projection 
of  the  base  of  the  fifth  metatarsal  bone  is  very  evident, 


Chap. xxiii.]      The  Ankle  and  Foot.  501 

and  extending  for  an  inch  or  so  behind  it  lies  the  cuboid 
bone. 

Joint  lines. — The  ankle-joint  lies  about  on  a  level 
of  a  point  \  an  inch  above  the  tip  of  the  inner  malleolus. 
Immediately  behind  the  tubercle  of  the  scaphoid  is  the 
astragalo-scaphoid  articulation,  and  a  line  drawn  trans- 
versely across  the  dorsum  of  the  foot,  just  behind  the 
process,  very  fairly  corresponds  to  the  mid-tarsal  joint 
(the  joint  compounded  of  the  astragalo-scaphoid  and 
calcaneo-cuboid  articulations). 

PIf  the  latter  articulation  be  approached  from  the 
outer  side  it  will  he  opposite  a  point  midway  between 
the  outer  malleolus  and  the  prominent  base  of  the  fifth 
metatarsal  bone. 

The  lines  of  the  articulations  between  the  first  and 
fifth  metatarsal  bones  and  the  inner  cuneiform  and 
the  cuboid  respectively  are  easily  indicated,  being  placed 
just  behind  the  bases  of  the  former  bones.  The  meta- 
tarso-phalangeal  articulations  are  situated  about  1  inch 
behind  the  webs  of  the  corresponding  toes.  The  proximal 
phalanx  and  part  of  the  middle  are  buried  in  the  web. 

Tendons. — The  tendo  Achillis  stands  out  very  con- 
spicuously at  the  back  of  the  ankle,  and  between  it  and 
the  malleoli  are  two  hollows  which  are  evident  in  even 
obese  individuals.  Over  the  front  of  the  ankle  the 
ton  dons  of  the  extensor  muscles  are  readily  to  be  dis- 
tinguished, especially  when  the  joint  is  flexed.  From 
within  outwards  they  are :  the  tendons  of  the  tibialis 
anticus,  extensor  longus  pollicis,  extensor  longus  digit- 
orum,  and  peroneals  tertius.  Beneath  the  tendons  of  the 
extensor  of  the  toes,  and  on  the  outer  part  of  the  dorsum 
of  the  foot,  the  prominent  fleshy  mass  formed  by  the 
extensor  brevis  digitorum  can  be  felt  and,  when  in  action, 
seen.  Above  and  behind  the  inner  malleolus  the  tendons 
of  the  tibialis  posticus  and  flexor  longus  digitorum  can  be 
discerned,  the  former  lying  nearer  to  the  bone.  Nearer 
to  the  middle  line  runs  the  flexor  longus  pollicis.  Behind 
the  outer  malleolus  the  long  and  short  peroneal  tendons 
can  be  felt,  lying  close  to  the  edge  of  the  fibula,  the 
tendon  of  the  smaller  muscle  being  the  closer  to  it. 


502  Surgical  Applied  Ana tomy.  [Chap.  xxin. 

f^-  In  the  middle  of  the  sole  of  the  foot  the  resisting 
plantar  fascia  can  be  felt,  and  some  of  its  processes 
made  out  when  the  toes  are  drawn  up  by  the  extensors. 
The  fleshy  mass  on  the  inner  margin  of  the  foot  is  formed 
by  the  abductor  and  flexor  brevis  pollicis  ;  that  on 
the  outer  side  by  the  abductor  and  flexor  brevis  minimi 
digiti. 

Vessels. — The  anterior  tibial  artery  and  nerve  are 
placed  opposite  the  ankle  joint,  between  the  tendons  of 
the  extensor  proprius  pollicis  and  longus  digitorum. 
The  dorsal  artery  runs  from  the  middle  of  the  ankle 
to  the  interval  between  the  bases  of  the  first  and 
second  metatarsal  bones.  It  may  be  felt  pulsating 
against  the  bones  along  the  outer  side  of  the  extensor 
proprius  pollicis  tendon,  which  is  the  readiest  guide 
to  it.  The  plantar  arteries  start  from  a  point  midway 
between  the  tip  of  the  malleolus  interims  and  the 
centre  of  the  convexity  of  the  heel.  The  internal 
vessel  follows  a  line  drawn  from  this  point  to  the 
middle  of  the  under  surface  of  the  great  toe.  The 
external  vessel  crosses  the  sole  obliqiiely  to  within  a 
thumb's  breadth  of  the  base  of  the  fifth  metatarsal 
bone.  From  thence  it  turns  more  transversely  across 
the  foot,  running  inwards  over  the  bases  of  the  meta- 
tarsal bones  to  inosculate  with  the  dorsalis  pedis  artery 
at  the  back  of  the  first  interosseous  space.  On  the 
dorsum  of  the  foot  the  subcutaneous  veins  may  be  seen 
forming  an  arch  convex  towards  the  toes,  and  from 
the  ends  of  the  arch  vessels  may  be  followed  into  the 
internal  and  external  saphenous  veins. 

The  ankle  and  foot. — The  slim  about  the 
ankle  and  over  the  dorsum  of  the  foot  is  thin  and  but 
loosely  attached  to  the  subjacent  parts.  It  becomes 
readily  excoriated,  as  is  often  the  case  where  splints 
or  instruments  have  been  improperly  applied.  Since  the 
skin  over  the  malleoli  lies  directly  upon  the  bone,  while 
that  covering  the  dorsum  of  the  foot  is  but  slightly 
separated  from  the  bones  of  the  tarsus,  it  follows  that 
the  integuments  in  this  region  are  readily  contused, 
and  may  suffer  gangrene  from  an  amount  of  pressure 


Chap,  xxiii.]      The  Ankle  and  Foot.  503 

that  would  cause  but  little  trouble  in  other  parts.  Over 
the  sole  the  integument  is  dense  and  thick  in  all  those 
parts  thai  conic  in  contact  with  the  ground.  In  the 
normal  loot,  the  heel,  the  outer  margin  of  the  foot, 
and  thelineof  metatarsophalangeal  joints  arc  in  contact 
with  the  ground  when  the  sole  is  placed  Hat  upon  it. 
Along  the  inner  margin  of  the  foot  the  integument 
is  thin  and  fine.  The  skin  of  the  sole,  like  that  of  the. 
palm  of  the  hand,  is  remarkably  adherent  to  subjacent 
parts.  When  cut  it  shows  no  tendency  to  gape,  and 
thus  exploratory  incisions  made  into  the  part  (as  for 
the  discovery  of  foreign  substances)  have  often  to  be  of 
greater  dimensions  than  would  be  needed  elsewhere. 

The  subcutaneous  tissue  about  the  ankle  and  foot 
varies  greatly  both  in  quantity  and  character.  It  is 
abundant  and  well  provided  with  loose  fat  in  the 
immediate  neighbourhood  of  the  tendo  Achillis.  Over 
the  front  of  the  ankle  and  dorsum  of  the  foot  it  is  very 
lax  and  fairly  extensive,  although  possessing  but  little 
adipose  tissue  in  its  meshes.  In  the  sole  the  subcut- 
aneous tissue  is  most  developed  where  most  pressure 
is  received.  Thus,  beneath  the  heel  it  is  often  £  of  an  inch 
in  thickness,  and  is  more  extensively  distributed  along 
the  outer  than  along  the  inner  margin  of  the  foot. 
It  is  here  composed  mainly  of  little  lobules  of  fat  bound 
down  and  enclosed  by  numerous  fibrous  bands  that 
pass  vertically  from  the  skin  to  the  deep  fascia.  Over 
the  centre  of  the  sole  it  is  more  scanty,  and  the  union 
between  the  integument  and  the  plantar  fascia  is  more 
direct.  It  very  closely  resembles  the  subcutaneous 
tissue  found  in  the  palm  and  upon  the  scalp.  Beneath 
the  heel  it  forms  an  actual  pad  or  cushion  that  musl 
much  diminish  the  force  of  shocks  transmitted  to  the 
body  through  the  foot.  The  laxity  of  the  tissue  upon 
the  dorsum  of  the  foot  permits  of  great  swelling  occurring 
in  cases  of  diffuse  inflammation  of  the  part  and  in  con- 
ditions producing  oedema.  In  the  commencement  of 
general  dropsy  the  dorsum  of  the  foot  is  often  the  first 
part  of  the  whole  body  to  show  the  morbid  swelling. 
In  the  sole,  on  the  other  hand,  inflammatory  affections 


504  Surgical  Applied  Anatomy.  [Chap. xxm. 

and  effusions  of  various  kinds  can  produce  but  little 
external  change,  owing  to  the  unyielding  character 
of  the  parts  concerned.  Collections  of  pus  upon  the 
dorsum  may  form  readily  and  extend  rapidly,  but  in 
the  sole  of  the  foot  and  in  the  heel  the  abscess  remains 
small,  is  unable  to  spread,  and  causes  intense  pain  by 
reason  of  the  dense  structure  of  the  tissues  involved. 

The  integuments  of  the  foot  are  well  supplied  with 
nerves,  being  furnished  with  branches  from  no  less  than 
six  nerve  trunks,  the  museulo-cutaneous,  the  anterior 
tibial,  the  two  saphenous,  and  the  external  and  internal 
plantar. 

Many  Pacinian  bodies  are  found  upon  these 
cutaneous  branches,  and  end-bulbs  are  met  with  in  the 
skin  on  the  sole  of  the  dorsum.  It  must  be  remembered 
that  these  nerves  come  from  a  considerable  distance 
(the  long  saphenous  from  the  lumbar  plexus,  and  the 
remainder  from  the  sacral),  so  that  pain  experienced 
in  the  foot  may  be  due  to  causes  very  remotely 
situated.  Thus,  Sir  B.  Brodie  mentions  a  case  of 
severe  neuralgia  of  the  foot,  after  each  evacuation  of  the 
bowels,  caused  by  the  descent  and  pressure  of  internal 
piles.  The  integuments  of  the  foot  respond  acutely 
to  sensations  of  pain,  of  pressure,  of  temperature,  and 
to  certain  unwonted  forms  of  tactile  impression,  such 
as  tickling.  Tactile  sensibility,  however,  as  measured 
by  the  cethesiometer,  is  not  acute,  the  dorsum  of  the 
foot  •  showing,  in  regard  to  this  matter,  no  more 
sensitiveness  than  does  the  skin  of  the  buttock. 

Over  the  "  tread  of  the  foot,"  and  especially  under 
the  ball  of  the  great  toe,  the  peculiar  affection  known 
as  "  perforating  ulcer  "  is  most  commonly  met  with. 
This  ulcer  occurs  as  an  occasional  symptom  in  certain 
nerve  maladies,  and  particularly  in  locomotor  ataxy. 

The  fasciae  of  the  foot  and  the  tendons 
about  the  ankle. — The  fasciae  on  the  dorsum  occur- 
in  two  layers,  a  superficial  one  that  is  continued  from 
the  anterior  annular  ligament,  and  a  deeper  placed 
over  the  extensor  brevis  and  interossei  muscles.  These 
membranes  are  both  thin  and  insignificant,  and  exercise 


Chap,  xxiii.]      The  Ankle  and  Foot.  505 

no  influence  from  a  surgical  point  of  view.  The 
plantar  fascia  is  divided  into  three  parts,  a  central  or 
main  portion  which  is  extremely  dense  and  powerful, 
and  two  lateral  expansions  which  are  thin  and 
surgically  insignificant.  The  outer  of  the  two  lateral 
portions  is,  however,  of  some  substance,  and  forms  a 
very  thick  band  between  the  os  calcis  and  fifth  meta- 
tarsal bone,  that  may  become  rigidly  contracted  in 
some  forms  of  talipes.  The  central  expansion  assists 
greatly  in  supporting  the  antero-posterior  arch  of  the 
foot,  which  it  tends  to  maintain  in  the  manner  that 
the  bowstring  maintains  the  arch  of  the  bow. 

The  sinking  of  the  arch  that  occurs  in  "  flat  foot " 
is  associated  with  marked  yielding  of  this  fascia. 
The  plantar  fascia  is  often  found  much  contracted  (as 
a  rule,  secondarily)  in  certain  forms  of  club-foot,  such 
as  talipes  equinus  and  congenital  varus.  The  term 
'*  talipes  cavus  "  is  applied  to  a  deformity  that  depends 
mainly  or  entirely  upon  a  contraction  of  the  plantar 
Fascia.  The  best  place  in  which  to  divide  this  mem- 
brane is  at  a  spot  about  1  inch  in  front  of  its  attachment 
to  the  os  calcis.  This  is  its  narrowest  part,  and  the 
knife  (which  should  be  introduced  from  the  inner  side) 
will  be  behind  the  external  plantar  artery  which  runs 
beneath  the  expansion.  An  abscess  situated  beneath 
the  membrane  will  be  very  closely  bound  down,  and 
will  advance  in  any  direction  other  than  through  the 
membrane  itself  so  as  to  point  in  the  centre  of  the  sole. 
Such  deep  collections  cause  intense  pain,  and  often  much 
destruction,  before  they  are  discharged.  They  may 
open  upon  the  dorsum,  or  may  extend  up  along  the 
it'ii dons  to  the  region  of  the  ankle.  There  are  certain 
1  '< .lamina  or  spaces  in  the  substance  of  this  layer  occupied 
usually  by  fat.  Through  one  or  more  of  these  an  abscess 
will,  in  exceptional  cases  extend,  and  then  spread  out 
beneath  the  integuments.  Such  an  abscess  will  have, 
therefore,  two  cavities  united  by  a  small  hole,  and  will 
form  the  abc<s  en  bissac  or  en  bouton  de  chemise  of  the 
French.  The  plantar  fascia  divides  into  slips  near  the 
roots  of  the  toes,  and  forms  a  series  of  arches,  beneath 


506  Surgical  Applied  A na  to m y.  [Chap,  xxiii. 

which  pass  the  tendons,  vessels,  and  nerves  bound  for 
the  digits.  Two  intermuscular  septa  connected  with 
the  membrane  separate  the  flexor  brevis  digitorum  from 
the  abductor  pollicis  on  the  one  side  and  the  abductor 
minimi  digiti  on  the  other.  They  are,  however,  mem- 
branes of  too  feeble  a  structure  to  much  affect  the 
progress  of  a  deep  plantar  abscess. 

The  anterior  annular  ligament  is  divided  into  two 
parts  ;  an  upper  band  in  front  of  the  tibia  and  fibula, 
and  a  lower  band  in  front  of  the  upper  limits  of  the 
tarsus.  Beneath  the  former  there  is  only  one  synovial 
sheath,  that  for  the  tibialis  anticus  ;  beneath  the  latter 
are  three  sheaths  :  one  for  the  peroneus  tertius  and 
extensor  communis,  one  for  the  extensor  proprius 
pollicis,  and  a  third  for  the  tibialis  anticus. 

According  to  Holden,  there  is  often  a  large  irregular 
bursa  between  the  tendons  of  the  extensor  longus  digi- 
torum and  the  projecting  end  of  the  astragalus.  This 
bursa  sometimes  communicates  with  the  joint  of  the 
head  of  the  astragalus. 

Beneath  the  internal  annular  ligament  are  three 
synovial  sheaths  for  the  tendons  of  the  tibialis  posticus, 
flexor  longus  digitorum,  and  flexor  longus  pollicis. 
Inflammation  involving  the  sheath  for  the  tibialis  pos- 
ticus may  spread  to  the  ankle  joint,  with  which  the 
tendon  is  in  close  relation.  Beneath  the  outer  annular 
ligament  is  the  single  synovial  sheath  for  the  long  and 
short  peroneal  tendons. 

In  severe  sprains  of  the  ankle  not  only  are  the  liga- 
ments about  the  joint  more  or  less  ruptured,  but  the 
various  synovial  sheaths  just  named  are  apt  to  be  torn. 
The  long  abiding  trouble  in  the  part  that  often  follows 
severe  sprains  depends  to  a  great  extent  upon  damage 
to  these  sheaths,  and  to  extravasations  of  blood,  and 
subsequently  of  inflammatory  material,  within  them. 

There  are  few  foursae  of  any  magnitude  about  the 
foot,  save  one  between  the  tendo  Achillis  and  os  calcis, 
and  another  over  the  metatarso-phalangeal  joint  of 
the  great  toe.  The  first-named  bursa  rises  up  about 
\  an  inch  above  the  os  calcis,  and  bulges  out  on  either 


Chap,  xxiii.]      The  Ankle  and  Foot.  507 

side  of  the  tendon.  "When  inflamed  it  may  produce 
symptoms  like  those  of  ankle-joint  disease,  and  when 
suppurating  may  lead  to  caries  of  the  os  calcis.  The 
enlargement  of  the  bursa  over  the  metatarso-phalangeal 

joint  of  the  great  toe  constitutes  a  bunion.  It  lies  in  the 
subcutaneous  tissue  between  the  internal  sesamoid 
and  the  skin,  and  is  not  present  at  birth.  This  con* 
dition  is  generally  brought  about  by  improperly  shaped 
boots,  which  force  the  great  toe  outwards,  place  it 
obliquely  to  the  long  axis  of  the  foot  (with  which  it 
should  be  parallel),  and  render  the  metatarsal  joint 
very  prominent.  The  cartilage  over  the  inner  part  of 
the  head  of  the  metatarsal  bone  disappears,  and  a  com- 
munication between  the  bursa  and  joint  may  be  set  up. 
The  result  of  this  deformity  is  a  great  weakening  of  the 
toe  and  adjacent  part  of  the  foot,  a  lengthening  of  the 
internal  lateral  ligament  of  the  joint,  and  a  dis- 
placement outwards  of  the  tendon  of  the  extensor  pro- 
prius  pollicis.  Bursao  are  often  developed  over  the 
malleoli  in  tailors,  and  especially  over  the  external  pro- 
cess, the  part  most  pressed  upon  when  sitting  cross- 
legged.  In  club-foot,  bursa?  are  found  over  any  points 
that  are  exposed  to  undue  pressure. 

The  tendons  about  the  ankle  are  not  unfrequently 
ruptured  by  violence.  Those  that  most  often  are 
so  injured  are  the  tendo  Achillis  and  the  tendons 
of  the  tibialis  posticus,  and  long  and  short  peroneal 
muscles.  The  tendo  Achillis  usually  breaks  at  a  point 
about  l|  inches  above  its  insertion,  where  it  becomes 
narrowed  and  its  fibres  are  collected  into  a  very  definite 
bundle. 

In  some  forms  of  violence  the  synovial  and  fibrous 
sheaths  that  bind  down  a  tendon  may  be  ruptured 
and  it  may  be  allowed  to  become  displaced.  This  has  hap- 
pened to  the  tibialis  posticus  and  peroneal  muscles.  In 
each  instance  the  dislocated  structure  comes  forwards 
upon  or  in  front  of  the  malleolus.  No  tendon  in  the 
body  is  so  frequently  displaced  as  is  that  of  the  peroneus 
longus. 

The  tendons  about  the  ankle  are  frequently  divided 


508  Surgical  Applied  Anatomy.  [Chap,  xxiii. 

by  operation.  The  tendo  Achillis  is  usually  cut  about 
1  inch  above  its  insertion,  the  knife  being  entered  from 
the  inner  side  to  avoid  the  posterior  tibial  vessels.  The 
tibialis  posticus  tendon  is,  as  a  rule,  divided  just  above 
the  base  of  the  inner  malleolus.  There  is,  however, 
enough  room  between  the  annular  ligament  and  the 
scaphoid  bone  to  cut  it  on  the  side  of  the  foot.  The 
anterior  tibial  tendon  may  be  divided  readily  either 
in  front  of  the  ankle  or  at  its  insertion  into  the  internal 
cuneiform  bone.  On  section  of  a  tendon  a  gap  is  felt, 
owing  to  retraction  by  the  muscle.  The  cut  ends  are 
still  united  by  the  fibrous  tissue  in  which  they  lie,  and 
from  which  they  derive  their  blood  supply.  If  cut 
within  a  sheath  the  synovial  membrane  forms  a  loose 
binding  between  the  cut  ends.  A  fibrous  band  between 
the  cut  ends  is  ultimately  formed  from  the  effusion 
which  fills  the  gap.  The  new  band  is  firmly  adherent 
to  the  sheath  in  which  it  lies,  and  at  first  will  limit  the 
movements  of  the  tendon. 

Part  of  the  tendon  of  a  sound  muscle  may  be  yoked 
to  that  of  one  which  has  become  paralysed,  thus  restoring 
certain  movements  to  the  foot. 

BBood-vessels. — The  lines  of  the  various  arteries 
have  been  already  indicated.  Wounds  of  the  plantar 
arch  are  serious,  on  account  of  the  depth  at  which  the 
external  plantar  artery  lies,  and  the  impossibility  of 
reaching  the  vessel  without  making  a  large  wound 
in  the  sole  that  would  open  up  important  districts  of 
connective  tissue  and  do  damage  to  tendons  and  nerves. 
The  arch  is  formed  by  the  junction  of  the  external 
plantar  artery  with  the  dorsal  artery  of  the  foot,  a  con- 
tinuation of  the  anterior  tibial  vessel.  In  cases,  how- 
ever, of  bleeding  from  the  arch,  ligature  of  both  the 
posterior  and  anterior  tibial  vessels  at  or  just  above  the 
ankle  would  not  necessarily  arrest  the  haemorrhage. 
After  ligature  of  these  vessels  blood  would  still  be  brought 
indirectly  to  the  arch  by  means  of  the  peroneal  artery. 
By  its  anterior  peroneal  branch  this  vessel  communicates 
with  the  external  malleolar  branch  of  the  anterior  tibial 
artery,  and  with  the  tarsal  branch  of  the  dorsalis  pedis. 


Chap,  xxiii.]      The  Ankle  and  Foot.  509 

By  its  terminal  branch  it  communicates  with  the  two 
last-named  vessels,  and  also  with  the  internal  calcaneal 
branches  of  the  external  plantar  artery.  As  a  matter 
of  practice,  however,  elevation  of  the  limb,  together 
with  pressure  upon  the  wounded  point  and  com- 
pression of  the  main  artery,  are  sufficient  to  check  most^ 
haemorrhages  from  the  plantar  arch. 

It  must  be  remembered  that  this  arch  can  be 
wounded  by  penetrating  wounds  inflicted  upon  the 
dorsum  of  the  foot ;  and  Dr.  Delorme  has  shown  how 
readily  various  parts  of  the  arch  may  be  ligatured  from 
the  dorsum  after  portions  of  one  or  other  of  the  meta- 
tarsal bones  have  been  removed.  Thus  by  resecting 
t  lie  upper  part  of  the  shaft  of  the  fourth  metatarsal 
bone  in  one  case,  the  main  part  of  the  shaft  of  the  third 
bone  in  another,  and  the  upper  part  of  the  shaft  of  the 
second  bone  in  a  third  instance,  he  has  been  enabled 
to  expose  and  ligature  the  greater  part  of  the  plantar 
arch  from  the  dorsal  aspect  of  the  foot. 

The  dorsalis  pedis  artery,  from  its  superficial  posi- 
tion and  its  close  contact  with  the  bones  of  the  foot, 
is  frequently  divided  in  wounds  and  ruptured  in  severe 
contusions.  The  posterior  tibial  artery  at  the  ankle 
is  well  protected  by  the  projecting  malleolus,  the  dense 
annular  ligament,  and  the  tendons  that  run  by  its  side. 

The  superficial  veins  of  the  foot,  like  those  of  the  hand, 
are  found  mainly  upon  the  dorsum  of  the  member. 
The  sole,  as  a  part  exposed  to  pressure,  is  singularly 
free  from  them.  About  the  malleoli,  and  especially 
about  the  inner  process,  these  veins  form  a  considerable 
plexus.  Hence  it  is  that  appliances  that  fit  tightly 
around  the  ankle  are  apt  to  produce  oedema  and  pain  in 
the  parts  beyond.  The  dull  pain  in  the  feet  that  is  often 
caused  by  tight  elastic-side  boots  is  probably  due  to  the 
same  cause.  It  will  be  understood  that  wounds  and 
suppurations  about  the  dorsum  of  the  foot  are  more  apt 
to  be  attended  by  phlebitis  than  are  like  lesions  when 
situated  upon  the  sole.  Venesection  is  sometimes  per- 
formed in  the  foot,  the  vein  opened  being  either  one  of 
those  forming  the  dorsal  plexus,  or  more  usually  the 


510  Surgical  Applied  Anatomy.  [Chap  xxm. 

internal  saphenous  vein  just  above  the  malleolus.  The 
vessels  are  rendered  conspicuous  by  placing  the  foot 
in  hot  water  and  then  applying  a  constricting  band 
around  the  leg. 

The  lymphatics  form  a  very  fine  and  elaborate 
plexus  in  the  coverings  of  the  sole,  from  which  vessels 
arise  that  reach  the  borders  and  dorsum  of  the  foot, 
and  principally  the  inner  border.  The  main  lymph 
vessels  of  the  part  are  found  upon  the  dorsum  and 
about  the  radicles  of  the  two  saphenous  veins.  Those  on 
the  inner  side  of  the  foot  are  by  far  the  more  numerous  ; 
they  follow  pretty  generally  the  course  of  the  internal 
saphenous  vein,  and  end  in  the  inguinal  glands.  The 
external  vessels  pass  up  along  the  outer  ankle  and  outer 
side  of  the  leg.  The  bulk  of  them  pass  obliquely  across 
the  ham  to  join  the  inner  set  above  the  knee  ;  others 
reach  the  inner  set  by  crossing  the  front  of  the  tibia, 
while  a  few  follow  the  short  saphenous  vein  and  end  in 
the  popliteal  glands.  Thus,  so  far  as  the  foot  is  con- 
cerned, lymphangitis  is  more  common  after  wounds 
of  the  dorsum  than  after  wounds  of  the  sole,  although  in 
the  latter  locality  the  frequent  retention  of  pus  beneath 
the  dense  fascia  greatly  favours  lymphatic  inflammations. 
Since  many  vessels  cross  the  shin  on  their  way  from  the 
outer  to  the  inner  set  of  vessels,  it  will  be  seen  that 
abrasions,  etc.,  of  that  part  of  the  limb  are  very  apt  to  be 
followed  by  inflammation  of  the  lymph  canals.  A 
lesion  on  the  inner  side  of  the  foot,  and  most  lesions  on 
the  dorsum,  will  be  associated  with  enlargement  of  the 
inguinal  glands  ;  while  a  like  mischief  on  the  outer 
border  of  the  foot  may  affect  either  the  inguinal  or 
the  popliteal  chain  of  glands. 

The  ankle-joint  is  a  very  powerful  articulation, 
its  strength  being  derived  not  only  from  the  shape  of 
its  component  bones,  but  also  from  the  unyielding 
ligaments  and  many  tendons  that  are  bound  about  it 
like  straps.  Of  the  ligaments,  the  two  lateral  are  very 
strong,  and  have  an  extensive  hold  upon  the  foot.  The 
anterior  and^posterior  are  extremely  thin  and  insignifi- 
cant,  although  thejatter  is  supported  by  the  tendon 


chap,  xxiii.]      The  Ankle  and  Foot.  511 


of  the  flexor  longus  pollicis,  which  crosses  it.  When 
effusion  takes  place  into  the  joint,  it  first  shows  itself  in 
front,  beneath  the  extensor  tendons,  and  just  in  front 
of  the  lateral  ligaments.  This  is  due  to  the  feebleness 
of  the  anterior  ligament  and  the  extent  and  looseness 
of  the  synovial  sac  in  relation  with  that  structure.  More 
extensive  effusions  cause  a  bulging  behind  through 
yielding  of  the  thin  posterior  part  of  the  capsule,  and 
fluctuation  can  then  be  obtained  on  either  side  of  the 
tendo  Achillis.  In  no  ordinary  case  can  fluctuation 
be  detected  distinctly  beneath  the  unyielding  lateral 
ligaments.  Moreover,  the  loose  synovial  sac  of  the 
ankle-joint  extends  both  in  front  and  behind  beyond 
the  limits  of  the  articulation,  while,  at  the  sides,  it  is 
strictly  limited  to  the  joint  surfaces.  The  ankle  is  a 
perfect  hinge-joint,  and  permits  only  of  flexion  and 
extension.  The  very  slightest  amount  of  lateral  move- 
ment is  allowed  in  extreme  extension,  when  the  narrower, 
or  hinder,  part  of  the  astragalus  is  brought  into  contact 
with  the  widest,  or  anterior,  part  of  the  tibio-fibular 
arch.  When  obvious  lateral  movement  exists  at  the 
ankle,  the  joint  must  be  the  seat  of  either  injury  or 
disease;  and  it  is  important  not  to  mistake  the  lateral 
movements  permitted  between  certain  of  the  tarsal 
bones  for  movements  at  the  ankle-joint.  Flexion  is 
limited  by  the  posterior  and  middle  parts  of  the  internal 
ligament,  by  the  posterior  part  of  the  external  liga- 
ment, l'\  the  posterior  ligament,  and  by  the  contact 
of  the  astragalus  with  the  tibia.  Extension  is  limited 
by  the  anterior  fibres  of  the  inner  ligament,  the  anterior 
and  middle  parts  of  the  outer  ligament,  by  the  anterior 
part  of  the  capsule,  and  the  contact  of  the  astragalus 
with  the  tibia. 

Owing  to  its  exposed  position,  this  joint  is  very 
liable  to  become  inflamed  from  injury  or  other  external 
causes.  When  inflamed,  no  distortion  is,  as  a  rule, 
produced,  the  foot  remaining  at  right  angles  with  the 
leg.  It  would  appear  that  this  position  is  due  to  the 
circumstances  that  the  flexor  and  extensor  muscles 
about  balance  one  another,  and  it  does  not  seem  that 


5*2  Surgical  Applied  Anatomy,  [Chap,  xxi  i. 

the  capacity  of  the  joint  is  affected  by  the  posture  of 
the  foot.  The  synovial  cavity  of  the  ankle  is  in 
communication  with  the  inferior  tibio-fibular  articu- 
lation. 

In  connection  with  the  subject  of  "  referred  pains," 
it  should  be  remembered  that  the  nerves  supplying 
the  ankle-joint  bring  that  articulation  into  relation 
with  the  lumbar  segments  of  the  spinal  cord  through 
the  internal  saphenous,  and  the  sacral  segments 
through  the  anterior  tibial  nerve. 

Dislocations  at  the  ankle-joint. — The  foot 
may  be  dislocated  at  the  ankle  in  five  directions,  which, 
placed  in.  order  of  frequency,  are,  outwards,  inwards, 
backwards,  forwards,  and  upwards  between  the  tibia 
and  fibula.  These  dislocations  are  nearly  ahvays 
associated  with  fracture  of  either  the  tibia  or  fibula, 
or  of  both  bones. 

1.  The  lateral  dislocations:  Outwards,  inwards. 
These  luxations  differ  somewhat  from  those  met  with 
in  other  joints.  In  the  great  majority  of  cases  they 
consist  of  a  lateral  twisting  of  the  foot,  of  such  a  kind 
that  the  astragalus  is  rotated  beneath  the  tibio-fibular 
arch.  There  is  no  great  removal  of  the  upper  surface 
of  the  astragalus  from  that  of  the  tibia,  but  rather 
is  one  or  other  edge  of  the  former  bone  brought  in 
contact  with  the  horizontal  articular  surface  of  the 
latter.  Although  much  deformity  is  produced,  the 
actual  separation  of  the  foot  from  the  leg  is  not  con- 
siderable. In  some  rare  cases  a  true  lateral  dislocation 
in  the  horizontal  direction  has  been  met  with. 

These  injuries  are  due  to  sudden  and  violent  twistings 
of  the  foot,  and  are  in  nearly  every  instance  associated 
with  fractures  of  the  tibia  or  fibula.  The  luxation 
outwards  is  due  to  forcible  eversion  of  the  foot,  the 
luxation  inwards  to  violent  inversion. 

It  is  of  interest,  in  the  first  place,  to  note  the  relation 
of  the  fibula  to  injuries  at  the  ankle-joint,  especially 
as  a  fracture  of  the  lower  end  of  the  shaft  of  that  bone 
may  follow  alike  upon  both  inversion  and  eversion 
of  the  foot.     The  lower  3  or  4  inches  of  the  fibula  may 


Chap,  xxiii.]      The  Ankle  and  Poor. 


5i3 


be  considered  to  form  a  lever  of  the  first  kind  (Fig.  70,  a)  . 
The  fulcrum  is  at  the  inferior  tibio-fibular  articulation, 
one  arm  of  the  lever  is  the  malleolus  below  that  joint, 
while  the  other  arm  may  be  regarded  as  formed  by 
the  lower  2  or  3  inches  of  the  shaft  of  the  bone.     Xow 


Pig.  70.  —Diagrams  to  illustrate  the  Mechanism  involved  in  Fractures 
of  the  Lower  End  of  the  Fihula. 

A,  Parts  in  normal  position;  a,  tibio-fibular  ligaments;  6,  external  lateral  liga- 
ment;  c,  internal  lateral  ligament;  b,  fracture  of  fibula  clue  to  eversiou  of 
foot  ;  0,  fracture  of  tllmia  due  to  inversion  of  foot. 


the  lower  ends  of  the  tibia  and  fibula  are  bound  together 
by  very  powerful  ligaments,  viz.,  the  anterior  and 
posterior  tibio-fibular,  the  transverse,  and  the  inferior 
interosseous.  I  would  venture  to  particularly  insist 
that  in  no  ordinary  lesion  about  the  ankle,  whether 
fracture  or  dislocation,  do  these  ligaments  give  way. 
If  they  should  yield,  then  an  anomalous  form  of  fracture 

-h 


5'i 4  Surgical  Applied  Anatomy.  [Chap,  xxiii. 

or  luxation  will  be  produced.  In  forcible  eversion 
of  the  foot,  the  internal  lateral  ligament  becomes 
stretched  and  tears,  the  astragalus  is  rotated  laterally 
beneath  the  tibio-fibular  arch  and  is  brought  into  violent 
contact  with  the  end  of  the  outer  malleolus.  This 
process  is  pushed  outwards,  and  acts  as  one  end  of  a 
lever.  The  fulcrum  is  secured  by  the  unyielding  tibio- 
fibular ligaments,  and  the  fibula  breaks  at  the  other 
end  of  the  lever,  a  point  some  2  or  3  inches  above  the 
end  of  the  bone  (Fig.  70,  b).  In  forcible  inversion  of 
the  foot,  the  astragalus  undergoes  a  little  lateral  rotation 
in  the  opposite  direction  ;  the  external  lateral  ligament 
is  greatly  stretched,  and  tends  to  drag  the  end  of  the 
outer  malleolus  inwards.  If  the  ligament  yields,  the 
case  will  probably  end  as  a  sprained  ankle,  or  pass  on 
to  a  dislocation  inwards  of  the  foot.  But,  if  it  remains 
firm,  the  end  of  the  fibular  lever  (the  tip  of  the  malleolus) 
is  drawn  towards  the  middle  line,  the  fulcrum  is  secured 
by  the  tibio-fibular  ligaments,  and  the  shaft  breaks 
at  the  other  end  of  the  lever,  some  few  inches  above 
the  end  of  the  bone  (Fig.  70,  c).  It  will  be  seen  that 
in  the  fracture  due  to  eversion  the  upper  end  of  the 
lower  fragment  is  displaced  towards  the  tibia,  while, 
in  the  lesion  due  to  inversion,  it  is  displaced  from  that 
bone.  From  a  careful  examination  of  all  the  cases 
of  fracture  of  the  lower  end  of  the  fibula  admitted  into 
the  London  Hospital  during  the  time  I  held  the  post 
of  surgical  registrar  there,  I  convinced  myself  that  the 
lesion  is  much  more  frequently  due  to  eversion  than  to 
inversion  of  the  foot.  I  think  it  may  be  said  that  a 
fracture  of  the  lower  end  of  the  fibula  due  to  simple 
inversion  of  the  foot  is  not  possible  unless  the  external 
lateral  ligament  remains  entire. 

In  the  outward  luxation,  better  known  as  Pott's 
fracture,  the  condition  is  such  as  has  just  been  described 
in  connection  with  the  effects  of  eversion  of  the  foot 
upon  the  fibula.  That  bone  is  always  broken  some 
2  or  3  inches  above  the  malleolus,  the  deltoid  ligament 
is  torn,  or  the  tip  of  the  inner  malleolus  wrenched  off. 
The  astragalus  is  so  rotated  laterally  that  the  foot  is 


chap,  xxiii.]      The  Ankle  and  Foot.  515 

much  everted,  its  outer  edge  is  raised,  while  its  inner 
edge  rests  upon  the  ground.  The  inferior  tibiofibular 
ligaments  remain  intact.  If  they  yield,  an  unusual 
form  of  fracture  or  dislocation  is  produced,  as  already 
stated.  Boyer  relates  a  case,  considered  to  be  unique, 
where  the  foot  was  luxated  outwards,  but  without 
any  fracture  of  the  fibula.  That  bone,  however,  had 
been  forced  upwards  entire,  and  its  head  dislocated 
from  the  articular  facet  of  the  tibia.  A  horizontal 
dislocation  outwards,  without  rotation  of  the  foot  and 
without  fracture  of  the  fibula,  is  possible  if  the  inferior 
tibio-fibular  ligaments  are  entirely  torn. 

In  Dupuytrens  fracture  (a  rare  injury)  the  fibula 
is  fractured  from  1  to  3  inches  above  the  malleolus, 
the  inferior  tibio-fibular  ligaments  are  entirely  lacerated, 
or  the  portion  of  the  tibia  to  which  they  are  attached 
is  torn  away,  and  remains  connected  with  the  lower 
fragments  of  the  fibula.  The  foot  is  dislocated 
horizontally  outwards,  and  is  drawn  upwards,  the 
extent  of  the  upward  displacement  depending  upon 
the  height  at  which  the  fibula  breaks. 

In  the  imvard  luxation  the  external  lateral  ligament 
is  torn  or  the  tip  of  the  outer  malleolus  dragged  away, 
the  deltoid  ligament  is  intact,  but  the  internal  malleolus 
is  commonly  broken  by  the  violence  with  which  the 
astragalus  is  brought  into  contact  with  it.  That  bone 
itself  may  be  broken,  and  is  in  any  case  rotated  laterally, 
so  that  the  foot  is  inverted  and  its  inner  border  much 
raised.  In  all  forms  of  this  dislocation,  whether  simple 
or  complicated,  the  inferior  tibio-fibular  ligament  remains 
intact. 

2.  The  antero-posterior  dislocations :  Backwards ; 
forwards.  These  injuries  are  brought  about  by  great 
force  applied  to  the  foot  while  the  leg  is  fixed,  or  more 
commonly  by  sudden  arrest  of  the  foot  during  some 
violent  impulse  given  to  the  body,  as  on  jumping  from 
a  carriage  when  in  motion.  In  the  luxation  backwards 
the  astragalus  is  displaced  behind  the  tibia,  while  the 
articular  surface  of  the  latter  bone  rests  upon  the  scaph- 
oid and  cuneiform  bones.     The  anterior  and  posterior 


5«6 


Surgical  Applied  Anatomy.  [Chap.  xxm. 


ligaments  are  entirely  torn,  and  a  great  part  also  of  the 
two  lateral  bands.  The  fibula  is  broken  some  2  or 
3  inches  above  the  malleolus,  and  there  is  usually  a 
fracture  also  of  the  inner  malleolus. 

The  luxation  forwards  is  of  extreme  rarity.  In 
the  few  reported  cases  one  or  both  malleoli  were  broken. 
R.  W.  Smith  believes  that  the  dislocation  is  never 
complete. 

3.  The  dislocation  upwards.     In  this  rare  accident 


3 

FiEr.,71. 


-Antero-  Posterior  Section  of  the  Foot  (Eudinger). 


1,  Tibia ;  2,  astragalus  :  3,  ns  cnlcis  :  4,  scaphoid  ;  5,  int.  cuneiform  ;  6,  first 
metatarsal  bone ;  7  and  8,  phalanges  of  great  toe. 


the  inferior  tibio-fibular  ligaments  are  ruptured,  the 
two  bones  are  widely  separated  at  their  lower  ends,  and 
the  astragalus  is  driven  up  between  them.  The  anterior 
and  posterior  ligaments  are  entirely  ruptured,  but  the 
lateral  ligaments  usually  escape  with  but  some  slight 
laceration.  The  accident  appears  to  be  generally  caused 
by  a  fall,  the  patient  alighting  flat  upon  the  soles  of  the 
feet.  Mr.  Bryant  records  a  case  in  which  both  feet 
were  similarly  dislocated  upwards. 

The  foot. — There   are   two  arches  in  the  foot,  an 
antero-posterior  and  a  transverse. 


Chap,  xxiii.]       The  Ankle  and  Foot.  517 

1.  The  anteroposterior  arch  has  its  summit  at  the 
astragalus.  It  may  be  considered  as  composed  of  two 
piers.  The  hinder  pier  consists  of  the  os  calcis,  the 
anterior  pier  of  the  scaphoid,  cuneiform  and  metatarsal 
bones.  The  astragalus  forms  the  keystone  of  the  arch, 
the  head  of  the  bone  especially  performing  that  function 
(Fig.  71). 

The  foot  rests  upon  the  heel,  the  heads  of  the 
metatarsal  bones,  and  the  outer  margin  of  the  foot 
(Fig.  72).  The  hinder  pier  is  solid,  is  made  up  of  a 
strong  bone,  and  contains  only  one  joint.  It  serves  to 
support  the  main  part  of  the  weight  of  the  body,  and 
gives  a  firm  basis  of  attachment  to  the  muscles  of  the 
calf.  The  anterior  part  of  the  arch,  on  the  other 
hand,  contains  many  small  bones  and  a  number  of 
complicated  joints.  It  serves  to  give  elasticity  to  the 
foot,  and  to  diminish  the  effect  of  shocks  received  upon 
the  sole  of  the  foot.  The  comparative  value  of  the  two 
piers  of  the  arch  in  this  latter  respect  can  be  estimated 
by  jumping  from  a  height  and  alighting  first  upon  the 
heels  and  then  upon  the  balls  of  the  toes.  The  inner 
part  of  the  arch  is  much  more  curved  than  the  outer, 
and  forms  the  instep. 

2.  The  transverse  arch  is  most  marked  across  the 
cuneiform  bones.  It  gives  much  elasticity  to  the 
foot    and   affords    protection    to    the   vessels    of    the 

sole. 

These  two  arches  result  from  the  shape  of  the 
component  bones,  and  are  maintained  by  the  various 
ligaments  and  muscles  of  the  sole.  The  peroneals  longus 
tendon,  and  nearly  all  the  ligaments  which  connect 
the  first  and  second  rows  of  tarsal  bones  on  both  the 
plantar  and  dorsal  aspects,  are  inclined  forwards  and 
inwards,  and  by  this  arrangement  are  well  adapted 
to  maintain  the  integrity  of  the  transverse  as  well  as 
of  the  antcro-posterior  arch. 

The  chief  joints  of  the  foot. — The  articulation 
between  the  os  calcis  and  astragalus  forms  a  double 
joint.  The  posterior  joint,  that  behind  1  he  interosseous 
ligament,  has  a  separate  synovial  sac,  while  the  anterior 


518  Surgical  Applied  Anatomy.  [Chap,  xxiii. 

communicates  with  the  synovial  cavity  of  the  mid-tarsal 
articulation.  The  two  bones  are  held  together  not 
only  by  the  interosseous,  the  internal,  external,  and 
posterior  calcaneo-astragaloid  ligaments,  but  are  sup- 
ported also  by  the  external  calcaneo-scaphoid  ligament, 
the  two  lateral  ligaments  of  the  ankle,  and  the  tendons 
about  the  part.  The  articulation  permits  of  adduction 
and  abduction,  and  of  some  rotation  of  the  foot  beneath 
the  astragalus.  Adduction  is  associated  with  some 
turning  of  the  toes  inwards  in  the  movement  of  inversion, 
and  abduction  with  some  turning  of  them  outwards 
in  eversion  of  the  foot. 

Dislocation  of  the  astragalus. — This  bone 
is  sometimes  luxated  alone,  being  separated  from  its 
connections  with  the  os  calcis,  the  tibia,  the  fibula, 
and  the  scaphoid  bone.  The  displacement  may  be 
either  forwards,  backwards,  or  laterally.  The  lateral 
luxations  are  nearly  always  oblique,  the  bone  passing 
as  a  rule  forwards  as  well  as  inwards  or  outwards.  The 
luxation  forwards  is  by  far  the  most  common  lesion, 
the  next  in  frequency  being  a  luxation  outwards  and 
forwards.  The  backward  displacement  is  extremely 
rare.  The  dislocations  are  usually  complete,  are  very 
often  compound,  especially  when  in  the  lateral  direction, 
and  are  commonly  associated  with  fracture  of  the  tibia 
or  fibula,  or  of  the  astragalus  itself.  A  lateral  complete 
dislocation  is  impossible  without  fracture  of  one  or 
other  malleolus.  In  these  injuries  the  interosseous 
ligament  between  the  os  calcis  and  astragalus  is  entirely 
torn,  as  are  also  the  greater  part  of  the  lateral  ligaments 
of  the  ankle,  and  the  various  bands  that  connect  the 
astragalus  with  the  os  calcis  and  scaphoid.  In  all  in- 
stances the  malleoli  are  brought  nearer  to  the  sole.  In 
the  antero-posterior  luxations  the  foot  as  a  rule  undergoes 
no  rotation,  but  in  the  luxation  of  the  bone  forwards 
and  outwards  it  becomes  inverted,  and  in  the  displace- 
ment forwards  and  inwards  everted. 

Dislocation  of  the  os  calcis. — This  bone, 
although  often  fractured,  is  very  rarely  luxated.  When 
displaced,   however,   it  is   usually   displaced   outwards, 


chap,  xxiii.]      The  Ankle  and  Toot.  519 

and  is  torn  away  from  its  attachments  to  the  astragalus 
and  cuboid,  or  from  the  former  bone  alone. 

Suhastragaloid  dislocations   of   the  foot. 

— In  these  lesions,  which  are  not  very  uncommon,  the 
astragalus  remains  in  position  between  the  tibia  and 
fibula,  while  the  rest  of  the  foot  is  dislocated  below 
that  bone.  The  luxation,  therefore,  concerns  the 
calcaneo-astragaloid  and  astragal o-scaphoid  joints.  The 
foot  may  be  displaced  either  forwards,  backwards, 
or  laterally.  The  forward  dislocation  is  extremely 
rare,  and  the  lateral  luxations  are  nearly  always  oblique. 
In  the  most  usual  displacements  the  foot  is  dislocated 
outwards  or  inwards,  and  is  at  the  same  time  carried 
backwards.  Thes°  luxations  are  often  compound, 
especially  when  lateral.  They  are,  as  a  rule,  incomplete 
as  regards  the  calcaneo-astragaloid  joint,  while,. on  the 
other  hand,  the  displacement  of  the  astragalus  from 
the  scaphoid  is  in  nearly  every  instance  complete.  In 
all  cases  the  interosseous  ligament  between  the  os  calcis 
and  astragalus  must  be  torn,  and  there  will  also  be 
more  or  less  laceration  of  the  astragalo-scaphoid  ligament, 
and  of  one  or  both  of  the  lateral  bands  of  the  ankle 
joint.     The  malleoli  are  very  often  fractured. 

It  is  only  necessary  to  notice  in  any  detail  the  two 
literal  luxations,  as  being  the  only  common  forms.  In 
the  inward  dislocation  the  foot  is  inverted,  its  inner 
border  is  raised,  is  shortened,  and  rendered  concave, 
while  its  outer  border  is  lengthened  and  made  convex. 
The  deformity  much  resembles  that  of  talipes  varus. 
The  head  of  the  astragalus  with  the  outer  malleolus 
forms  a  projection  at  the  outer  aspect  of  the  foot,  while 
below  them  a  deep  hollow  exists.  The  inner  border  of 
the  03  calcis  is  very  prominent  at  the  internal  side  of  the 
limb,  while  the  inner  malleolus  is  buried  in  the  hollow 
Left  by  the  displacement  of  that  bone.  The  calcaneum 
and  scaphoid  are  approximated.  Tn  the  outward  luxa- 
tion the  foot  is  abducted,  its  outer  border  is  raised,  and 
the  deformity  produced  is  not  unlike  that  of  talipes 
\  ilgus.  The  outer  malleolus  is  lost  in  the  hollow  caused 
by  the  eversion  of  the  foot,  while  the  tibial  malleolus 


520  Surgical  Applied  Anatomy.  [Chap. xxin. 

and  head  of  the  astragalus  form  a  projection  on  the 
inner  aspect  of  the  limb. 

The  inedio-tarsal  joint  is  composed  of  two 
articulations,  the  astragaio-scaphoid  and  calcaneo- 
cuboid. The  ligaments  supporting  the  former  joint 
are  the  external  and  inferior  calcaneo-scaphoid  and 
the  astragaio-scaphoid ;  while  the  latter  articulation 
is  maintained  by  the  internal  and  dorsal  calcaneo- 
cuboid ligaments,  and  the  long  and  short  plantar. 
Movement  is  somewhat  freer  in  the  astragaloid  than 
in  the  calcaneal  segment  of  the  joint.  The  movements 
permitted  in  the  articulation  as  a  whole  consist  of 
flexion  and  extension,  with  some  rotation  around  an 
antero-posterior  axis  whereby  the  sole  can  be  turned 
in  or  out.  Flexion  is  associated  with  inward  rotation 
of  the  sole  and  adduction  of  the  toes,  extension  with 
outward  rotation  of  the  sole  and  abduction  of  the  toes. 
It  should  be  noted  that  the  movements  of  turning  the 
toes  either  in  or  out  take  place  mainly  at  the  hip-joint ; 
while  the  turning  of  one  edge  of  the  foot  either  up  or 
down  is  a  movement  that  mostly  concerns  the  medio- 
tarsal  and  calcaneo-astragaloid  joints.  The  chief  de- 
formities in  club-foot  take  place  about  the  former 
articulation. 

Club  foot. — It  is  usual  to  divide  the  various 
forms  of  talipes,  or  club-foot,  into  four  main'  divisions, 
viz.  (l)  T.  equinus ;  (2)  T.  calcaneus ;  (3)  T.  varus ; 
and  (4)  T.  valgus.  Four  secondary  forms  result  from 
combinations  of  these  principal  varieties,  viz.  T. 
equino-varus,  T.  equino-valgus,  T.  calcaneo-varus,  and 
T.  calcaneo-valgus. 

1.  Talipes  equinus.  In  this  deformity  the  heel  is 
drawn  up,  and  the  patient  walks  upon  the  balls  of  the 
toes.  The  contracting  muscles  are  those  of  the  calf 
attached  to  the  tendo  Achillis.  In  a  well-marked  case 
the  os  calcis  is  much  raised,  and  may  even  be  brought 
in  contact  with  the  tibia.  The  astragalus  is  displaced 
downwards,  and  projects  upon  the  dorsum.  The  foot 
tends  to  become  more  and  more  bent  at  the  medio- 
tarsal  joint,  until  at  last  the  scaphoid  may  even  touch 


Chap,  xxiii.]      The  Ankle  and  Foot.  521 

the  os  calcis.     The  ligaments  of  the  sole  are  usually 
much  contracted. 

•1.  Talipes  calcaneus.  In  this  form  of  club-foot 
the  toes  are  drawn  up,  and  the  patient  walks  upon  the 
heel.  The  contracting  muscles  are  the  extensors  on 
the  anterior  aspect  of  the  limb.  The  os  calcis  is  ren- 
dered more  vertical,  and  the  astragalus  becomes  so 
obliquely  placed  that  part  of  its  upper  articular  surface 
may  project  beyond  the  tibia  in  a  backward  direction. 

3.  Talipes  varus.  This  is  the  commonest  form. 
Certain  features  of  the  foetal  foot  are  retained  in  an 
exaggerated  degree.  In  a  well-marked  congenital  case 
there  is  a  fourfold  deformity  :  (1)  The  heel  is  drawn  up 
by  the  muscles  attached  to  the  tendo  Achillis  ;  (2)  the 
foot  is  adducted  ;  and  (3)  its  inner  edge  is  drawn  up- 
wards by  the  contraction  of  the  tibialis  anticus  and 
posticus  ;  (4)  the  sole  is  contracted  by  the  flexor  longus 
digitorum  muscle  and  the  shrinking  of  the  plantar 
fascia  and  ligaments.  In  this  variety  of  talipes  the  os 
calcis  is  drawn  into  a  more  vertical  position.  The 
astragalus  is  displaced  forwards  and  downwards,  so  that 
some  part  of  its  upper  articular  surface  becomes  superficial 
on  the  dorsum.  The  neck  of  the  astragalus  is  elon- 
gated and  deflected  downwards  and  inwards  to  a  greater 
extent  than  in  the  normal  foot.  In  the  adult  the  neck  of 
the  astragalus  is  deflected  inwards  to  the  axis  of  its  body 
at  an  angle  of  10°  ;  in  the  newly  born  at  an  angle  of  25° ; 
and  in  talipes  varus  at  an  angle  of  50°.  The  scaphoid  is 
displaced  upwards  and  backwards,  until  its  inner  border 
often  touches  the  internal  malleolus.  The  three  cunei- 
form bones  follow  the  scaphoid,  and  the  cuboid  becomes 
the  lowest  bone  in  the  tarsus.  The  outer  border  of  the 
cuboid  forms  an  angle  with  the  os  calcis,  and  the  tendons 
of  the  peroneus  longus  slip  backwards  from  the  groove  in 
the  cuboid  to  lie  on  the  os  calcis.  The  anterior  border 
of  the  internal  lateral  ligament  is  contracted  and  unduly 
prominent. 

4.  In  talipes  valgus  the  foot  is  abducted  and  its 
outer  border  drawn  upwards.  The  contracting  muscles 
are    the    two    peronci.     In    a    well-marked    congenital 


522  Surgical  Applied  Anatomy.  [Chap.  xxm. 

case  the  os  calcis  is  found  a  little  raised  and  the  astrag- 
alus is  displaced  forwards  and  downwards.  The 
scaphoid  is  so  rotated  that  its  inner  part  is  depressed 
and  its  outer  raised.  The  internal  portion  of  the  bone 
forms  one  of  the  two  projections  obvious  on  the  inner 
side  of  the  foot,  the  other  prominence  being  formed 
by  the  head  of  the  astragalus.  The  cuboid  is  found 
to  be  a  little  rotated  outwards.  The  arch  of  the  foot  is 
lost,  and  all  those  ligaments  are  stretched  that  serve 
to  support  and  maintain  that  arch. 

Of  the  mixed,  or  secondary,  forms  of  talipes 
nothing  need  be  said.  They  are  the  results  merely  of 
a  combination  of  the  primary  varieties. 

As  trouble  is  often  caused  in  talipes  by  pressure 
being  brought  to  bear  upon  an  unusual  part  of  the 
foot,  it  is  well  to  note  upon  what  portion  of  the  mem- 
ber the  patient  treads  in  the  different  varieties  of  the 
deformity.  In  varus  the  "  tread "  is  mainly  upon  the 
outer  side  of  the  fifth  metatarsal  bone  ;  in  valgus  upon 
the  internal  malleolus  and  scaphoid  ;  in  equinus  upon 
the  bases  of  all  the  toes  ;  in  equino-varus  upon  the  base 
of  the  little  toe  ;  in  equino-valgus  upon  the  base  of  the 
great  toe  ;  in  all  forms  of  calcaneus  upon  the  heel.  In 
cases  of  extreme  and  obstinate  club-foot  wedges  of  bone 
are  sometimes  removed  by  the  operation  known  as 
Tarsectomy.  Thus  in  talipes  equino-varus  the  base  of 
the  wedge  will  be  on  the  outer  side  of  the  foot  and  will 
be  mainly  represented  by  the  cuboid  ;  the  apex  will  be 
at  the  scaphoid. 

FSat-foot  and  splay-foot  are  the  names  given 
to  a  deformity  due  probably  to  the  yielding  of  certain 
ligaments,  whereby  the  arch  of  the  foot  is  lost  and 
the  sole  becomes  more  or  less  perfectly  flat.  The  foot, 
at  the  same  time,  is  abducted,  and  the  outer  border  is 
often  a  little  raised,  so  that  the  patient  walks  mainly 
upon  the  inner  side  of  the  foot.  This  deformity  is  met 
with  in  those  who  stand  a  great  deal,  and  is  the  direct 
result  of  yielding  of  the  tarsal  ligaments  and  plantar 
muscles  from  long-continued  pressure.  When  the 
weight  of  the  body  is  brought  to  bear  on  the  foot  placed 


Chap,  xxiii.]      The  Ankle  and  Foot. 


523 


flat  upon  the  ground,  it  will  be  transmitted  in  an  oblique 
direction  from  above  downwards  and  inwards  (Fig.  72,  b'). 
The  foot,  therefore  tends  to  become  abducted,  a  tendency 
resisted   by  such    powerful  ligaments  as   the  internal 


Fi£ 


72  — Showing  some  of  the  Alterations  which  take  place  in  the  Arch 
in  Fiat-Foot. 


I.  The  skeleton  of  the  normal  foot 
.seen  from  above. 

v  b  c,  Line  of  the  inner  arch  formed 
by  the  <>s  calcis,  astragalus,  sca- 
phoid, internal  cuneiform,  and  first 
metatarsal  bone; 4  u'c.  the  line  of 
the  arch  in  flat-foot ;  x,  a  point  on 
the  astragalus  indicating  where 
the  centre  of  the  weight  of  the 
body  is  transferred  to  the  arch  ; 
x',  corresponding  point  in  flat- 
foot;  the  position  of  the  inferior 
calcaneo  Bcaphoid  ligament  is  in- 
dicated (i. c.s.  I.). 


II.  The  shaded  part  represents  the 
impress  of  a  normal  foot.  The 
stippled  area  represents  the 
additional  part  uf  the  arch  which 
rests  on  the  ground  in  flat-foot 

The  lines  a  b  0  and  a  b'  c  as  in  I. 


lateral  of  the  tinkle  and  those  connecting  the  os  calcis 
with  the  astragalus.  In  flat-foot  these  ligaments  yield, 
and  the  toes  consequently  are  turned  out  or  abducted. 
The  ligament,  however,  that  is  mainly  affected  in  this 
deformity  is  the  inferior  caicaneo-scaphoid.  This  strong 
baud  of  fibres  supports  the  head  of  the  astragalus  and 


524  Surgical  Applied  Anatomy.  [Chap,  xxiii. 

holds  up  the  keystone  of  the  plantar  arch.  When 
it  yields,  the  head  of  the  astragalus  is  pressed  forwards, 
downwards,  and  inwards  by  the  superincumbent  weight, 
and  the  foot  beyond  becomes,  as  a  consequence,  over- 
extended and  turned  out.  The  os  calcis  slants  inwards, 
and  its  anterior  end  is  depressed.  The  sustentaculum 
tali,  the  head  of  the  astragalus,  and  the  scaphoid  tubercle 
form  prominences  on  the  inner  side  of  the  foot,  and 
may  rest  on  the  ground  (Fig.  72).  The  long  and  short 
plantar  ligaments  also,  which  contribute  so  much  to  the 
maintenance  of  the  arch  of  the  foot,  in  time  yield,  and 
allow  of  a  still  greater  degree  of  deformity.  There  is  a 
stretching  also  of  the  deltoid  ligament.  In  neglected 
cases  the  distortion  is  rendered  more  or  less  permanent 
by  alterations  in  the  shape  of  the  tarsal  bones,  and  by 
a  contraction  of  such  ligaments  as  have  been  relaxed  by 
the  deformity.  The  foot  being  abducted,  and  its  outer 
border  a  little  raised,  the  peronei  muscles  become 
relaxed,  shortened,  and  contribute  to  the  permanency 
of  the  disorder.  It  will  be  understood  that  the  abnormal 
pressure  brought  to  bear  upon  the  various  tarsal  bones 
and  articulations  will  cause  severe  pain  to  be  often 
associated  with  this  affection.  The  calf  muscles  waste, 
owing  to  the  arch  of  the  foot  having  lost  its  rigidity 
and  being  no  longer  able  to  support  the  weight  of  the 
body. 

It  may  be  noted  that  the  medio-tarsal  joint,  which 
is  so  conspicuously  involved  in  the  distortion,  is  supplied 
by  the  anterior  tibial,  musculo-cutaneous,  and  external 
plantar  nerves. 

The  tarsal  bones,  owing  to  their  spongy 
character,  are  readily  broken  by  direct  violence,  as  in 
severe  crushes.  The  soft  parts  that  cover  these  bones 
being  scanty  upon  the  dorsal  aspect  of  the  foot,  it  follows 
that  these  accidents  are  often  compound  and  associated 
with  much  laceration  of  the  integuments. 

The  tarsal  bone  the  most  frequently  fractured  is 
the  os  calcis.  This  bone  may  be  broken  by  a  fall  upon 
the  heel,  and  in  many  instances  has  been  the  only  one 
fractured  by  such  an  accident.     A  few  cases  have  been 


chap,  xxiii.]      The  Ankle  and  Foot. 


525 


recorded  of  fracture  of  the  calcaneum  by  muscular 
violence,  the  muscles  producing  the  .lesion  being  those 
attached  to  the  tendo  Achillis.  Thus,  Sir  A.  Cooper 
reports  the  case  of  a  woman, 
aged  forty-two,  in  whom 
a  large  fragment  of  the 
posterior  part  of  the  os 
calcis  -was  torn  away  by 
the  muscles  and  drawn 
some  2 \  inches  away  from 
the  heel.  The  accident 
was  caused  by  her  taking 
a  false  step.  Abel  has 
collected  three  cases  of 
fracture  of  the  sustenta- 
culum tali.  He  believes 
that  this  injury  may  be 
produced  by  falls  upon  the 
sole  or  by  extreme  supina- 
tion (rotation  outwards)  of 
the  foot,  whereby  the  as- 
tragalus is  forced  violently 
against  the  process. 

The  astragalus  alone 
may  be  broken  by  a  fall 
upon  the  feet,  and  such 
accidents  are  often  associ- 
ated with  fractures  of  both 
that  bone  and  the  os  calcic 
It  must  be  noted,  however, 
that  in  a  fall,  when  the 
patient  alights  upon  the 
feet,  the  tibia  and  fibula 
arc  much  more  likely  to  be 
broken  than  are  the  tarsal 
bones,  since  the  bones  of 
the  leg  transmit  the  weight 
of  the  body  directly, 
whereas  that  weight  is 
much  diffused  and  broken 


Fig.  73.—Oblique  Autero-Posterior 
Section  of  the  Foot  (Rudiuger). 

1,  Tibia  ;  2,  fibula ;  3,  astragalus  ;  4,  os 

caii-is;  r>,  external  lateral  ligament  : 
6,  internal  lateral  ligament  ;  7,  inter- 
osseous I  ii-'aim'iit  i»'t  ween  astragalus 
and  os  calcis ;  8,  liead  of  astragalus  ; 
9.  scaphoid;  10,  11,  and  13,  the  three 
cuneiform  bones;  13,  cuboid. 


526  Surgical  Applied  Anatomy.  [Chap,  xxiii. 

up  when  passing    through    the    foot    with   its  many 
bones  and  joints. 

The  metatarsal  bones  and  phalanges  are  nearly 
always  broken  by  direct  violence.  1  had,  however, 
under  my  care  at  the  London  Hospital  a  man  who  had 
broken  the  shafts  of  the  three  outer  metatarsal  bones 
by  simply  slipping  off  the  edge  of  the  curb. 

With  regard  to  the  luxations  of  the  foot  not  yet 
considered,  it  may  be  said  that  the  cuboid  is  never 
dislocated  alone.  Walker  reports  a  case  of  dislocation  of 
the  scaphoid  alone,  that  structure  being  quite  separated 
from  the  astragalus  and  cuneiform  bones.  The  acci- 
dent was  brought  about  by  alighting  upon  the  ball 
of  the  foot  when  jumping,  and  the  little  bone  was  found 
projecting  on  the  dorsum.  Mr.  Bryant  has  mentioned 
an  instance  of  dislocation  of  the  scaphoid  inwards. 
As  a  rule,  however,  this  bone  when  displaced  is 
dislocated  along  with  the  astragalus. 

Of  the  cuneiform  bones  the  one  most  often  luxated 
alone  is  the  internal.  The  attachments  of  the  tendons 
of  the  tibialis  anticus  and  peroneus  longus  about  the 
internal  cuneiform  and  first  metatarsal  bones  renders 
it  common  for  the  latter  to  follow  its  tarsal  colleague 
when  dislocated.  Mr.  Luke  has  recorded  a  case  of 
incomplete  luxation  of  all  three  cuneiform  bones  upwards, 
and  at  least  three  cases  have  been  described  of  dislocation 
of  the  internal  bone  upwards  and  backwards,  together 
with  a  like  displacement  of  all  the  metatarsals. 

One  or  more  of  the  metatarsal  bones  may  be 
luxated,  or  the  entire  series  may  be  displaced  upwards, 
downwards,  inwards,  or  outwards,  the  first-named 
lesion  being  the  most  common.  In  rarer  instances, 
one  bone  has  been  thrown  in  one  direction  and  its  fellow 
or  fellows  in  another. 

Ossification  of  the  tarsus.— At  birth  the 
tarsus  is  mainly  cartilaginous.  Ossification  begins 
in  the  os  calcis  in  the  sixth  month  and  in  the 
astragalus  in  the  seventh  month  of  foetal  life.  The 
centre  for  the  cuboid  appears  at  birth,  and  in  the 
scaphoid,  the  last  to  ossify,  in  the  third  year.     It  is 


chap,  xxiii.]      The  Ankle  and  Foot.  527 

not  until  puberty  that  the  cartilage  of  the  tarsal  bone 
is  completely  ossified. 

Dislocation  of  the  proximal  phalanx  of  the  great  toe 
is  often  very  difficult  to  reduce,  as  is  also  the  case  in 
the  corresponding  luxation  of  the  thumb.  When  the 
displacement  is  dorsal,  the  difficulty  is  probably  due 
to  the  sesamoid  bones,  which  in  this  joint  take  the 
place  of  the  glenoid  ligament  or  fibro-cartilaginous 
plate  of  the  other  toes.  "  Like  the  glenoid  ligaments, 
the  sesamoid  bones  are  much  more  firmly  connected 
with  the  phalanx  than  with  the  metatarsal  bone,  and 
thus  get  torn  away  and  shut  back  behind  the  head  of 
the  metatarsal  bone  ;  or  it  may  be  that  the  sesamoid 
bones,  retaining  their  connections  with  the  lateral 
ligaments  of  the  joint  as  well  as  with  the  short  flexor 
tendons,  are  separated  from  one  another,  and  so  allow 
the  head  of  the  metatarsal  bone  to  pass  forwards,  and 
thus  become  nipped,  as  it  were,  in  a  button-hole  between 
them "  (Henry  Morris).  A  partial  dislocation  of  the 
proximal  phalanx  outwards  on  the  head  of  the  meta- 
tarsal bone  of  the  great  toe  constitutes  the  condition 
known  as  hallux  valgus.  The  inner  lateral  ligament 
of  the  joint  is  elongated,  while  the  outer  is  contracted. 
In  hallux  rigidus  this  joint  is  slightly  flexed  and  rigid, 
due  probably  to  a  reflex  contraction  of  the  flexor  brevis 
hallucis.  The  second  toe  is  commonly  longer  than  the 
others  and  is  more  liable  to  assume  the  form  known  as 
"  hammer  toe."  The  proximal  phalanx  in  such  a  form 
is  extended,  while  the  middle  is  strongly  flexed.  The 
condition  is  commonly  inherited  and  is  due  to  a  con- 
traction of  the  glenoid  and  lateral  ligaments  of  the 
proximal  phalangeal  joint.  The  extensor  tendon  is 
also  contracted. 

There  are  six  synovial  cavities  in  the  foot, 
excluding  that  of  the  ankle-joint,  viz.,  one  for  the  pos- 
terior calcaneo-astragaloid  joint,  a  second  for  the  anterior 
calcaneo-astragaloid  and  astragaloid-scaphoid  joints,  a 
third  between  the  os  calcis  and  cuboid,  a  fourth  between 
the  latter  bone  and  the  two  outer  metatarsals,  a  fifth 
for   the   joint   between   the  inner   cuneiform   and   first 


528 


Surgical  Applied  A na  to m y.  [Chap,  xxiii. 


metatarsal  bones,  and  a  sixth  for  the  remaining  articu- 
lations (Fig.  73).     These  synovial  cavities  tend  greatly 

to  diffuse  disease  among 
the  various  bones  of 
the  foot  when  once  one 
bone  has  become  in- 
flamed. The  best 
position,  therefore,  for 
bone  disease,  with  re- 
ference to  the  question 
of  extension,  would  be 
in  the  hinder  parts  of 
either  the  os  calcis  or 
astragalus,  and  one  of 
the  worst  positions 
would  be  assumed  by 
disease  involving  the 
scaphoid  bone. 

Syme's  ampu- 
tation at  the  ankle. 
— In  the  heel-flap  are 
cut  the  integuments, 
the  external  saphenous 
nerve  and  vein,  the 
peroneus  longus,  pe- 
roneus  brevis,  tibialis 
posticus,  flexor  longus 
digitorum,  flexor 
longus  pollicis,  tendo 
Achillis,  points  of 
origin  of  the  flexor 
brevis  digitorum  and 
of  the  two  abductor 
muscles,  and  the  in- 
ternal and  external 
plantar  arteries  and 
nerves. 
In  the  dorsal  flap  are  cut  the  integuments,  tibialis 
anticus,  extensor  communis  digitorum,  extensor  pro- 
prius  pollicis,   peroneus  tertius,   anterior   tibial  vessels 


Same's  Amputation  (Agatz). 


a,  Tibia;  b,  fibula:  c,  tibialis  anticus:  d, 
extensor  proprius  pollicis;  e,  extensor 
communis  digitorum  ;  f,  peroneus  tertius  ; 
if,  flexor  longus  pollicis  ;  h,  tibialis  posti- 
cus :  i,  flexor  loncrus  digitorum  ;j,  peroneus 
brevis:  k,  peroneus  longus;  I,  tendo 
Acliillis;  in,  some  muscles  of  the  sole  that 
are  not  usually  left  in  this  operation  ;  n, 
anterior  tibial  vessels;  o,  posterior  tibial 
vessels  ;  p,  posterior  tibial  nerve. 


Chap,  xxiii.]      The  Ankle  and  Foot. 


529 


and  nerve,  musculocutaneous  nerve,  and  internal 
saphenous  nerve  and  vein.  The  position  of  the  principal 
structures  divided  is  shown  in  Fig.  74.  It  is  not  usual 
to  dissect  up  any  of  the  muscular  tissue  of  the  sole,  as 
shown  in  Agatz's  plate.  It  should  be  noted  that  the 
integuments  of  the  heel  derive  their  blood  supply, 
which  is  very  free,  mainly  from  the  external  calcaneal 
branch  of  the  poste- 
rior peroneal  artery, 
and  the  internal 
calcaneal  from  the 
external  plantar. 

If  the  heel  in- 
cision is  carried  suf- 
ficiently far  back  to 
divide  the  trunk  of 
t  he  posterior  tibial 
artery,  the  heel  flap 
is  deprived  of  the 
last-named  source  of 
blood  supply.  The 
I  x  tsterior  tibial  artery 
bifurcates  upon  a 
line  drawn  from  the 
tip  of  the  inner  mal- 
leolus to  the  centre 
of  the  convexity  of 
the  heel. 

The  nerves  sup- 
plying the  integu- 
ments of  the  heel 
arc  the  calcaneal 
branch  of  the  ex- 
ternal saphenous  and  the  calcaneal  and  plantar  cutaneous 
twigs  from  the  posterior  tibial. 

In  Pirogoff's  amputation  the  parts  divided 
in  the  anterior  flap  are  the  same  as  in  Syme's  operation, 
in  the  heel  or  sole  flap  the  same  structures  also  are 
cut  as  in  the  corresponding  flap  in  a  Syme,  with  the 
exception  that   the  tendo  Achillis  is  not  divided,  the 


Fig.   7">.~Cliopart's  Operation  (Agatz). 

7,  Astragalus;  '>.  r>s  calcis;  c,  extensor  propriue 
pnllicis:  <'.  tibialis antious ;  e,  extensor  com- 
munis digitorum  ;  f.  peroneus  loneus ;  ^.alulur- 
tor  minimi  digiti :  n,  flexor  brevis  digitorum  ; 
f,  flexor  longusdigitoruin  :  /,  abductor  pollicis  ; 
k,  flexor  longus  pollicis;  l,dorsalis  pedis  artery  : 
m,  internal  plantar  artery;  n,  external  ?lautar 
artery. 


53° 


Surgical  Applied  Anatomy.  [Chap,  xxiii. 


flextfr  brevis  digitorum,  abductor  pollicis,  abductor 
minimi  digiti,  and  flexor  accessorius  are  divided  more 
extensively,  and  the  plantar  vessels  are  cut  farther 
from  the  bifurcation. 

€ho part's  operation  is  an  amputation  at  the 

medio-tarsal  joint.  In 
the  dorsal  flap  are  cut 
the  integuments,  the 
extensor  communis  and 
brevis  digitorum,  ex- 
tensor proprius  pollicis, 
tibialis  anticus,  pero- 
neus  tertius  and  brevis, 
the  musculo-cutaneous, 
anterior  tibial,  and  two 
saphenous  nerves,  the 
dorsal  artery,  and  the 
dorsal  plexus  of  veins. 
In  the  plantar  flap 
are  found  divided  the 
integuments,  plantar 
fascia,  flexor  brevis 
digitorum,  abductors  of 
the  great  and  little  toes, 
flexor  accessorius,  and 
tibialis  posticus  tendon. 
If  the  flap  be  well  dis- 
sected up  from  the 
bones,  parts  of  the 
short  flexors  of  the 
great  and  little  toes, 
the  abductor  pollicis, 
and  transversus  pedis 
will  be  found  cut  in 
the  flap.  The  tendons 
of  the  long  flexors  of  the  digits  and  great  toes,  the 
peroneus  longus,  and  the  plantar  vessels  and  nerves 
are  also  divided  (Fig.  75). 

Nj  Lisfranc's  operation,  or  amputation  through 
the  tarso-metatarsal  line  of  joints.    In  the  dorsal  flap 


Tig.  76.—  Lisfranc's  Operation  (Agatz). 

a,  b,  c,  Inner,  middle,  and  outer  cuneiform 
hones ;  d.  cuboid :  e,f,  the  metatarsal  bones ; 
g,  tibialis  anticus;  h,  extensor  proprius 
pollicis;  i,  extensor  c  minimis  digitorum  ; 
i,  extensor  brevis  digitorum  ;  k,  extensor 
tendons;  I,  dorsalis  pedis  artery. 


Chap,  xxiii.]      The  Ankle  and  Foot.  531 

the  same  structures  are  divided  as  are  cut  in  the 
corresponding  flap  in  Chopart's  amputation.  In  the 
plantar  flap  also  the  parts  divided  are  the  same  as  in 
that  procedure,  with  the  exception  that  the  flexor 
accessorius  and  the  tendon  of  the  tibialis  posticus  escape 
section.  In  opening  the  line  of  joints  it  should  be  noted 
that  the  articulations  between  the  three  outer  meta- 
tarsals and  [the  corresponding  tarsal  bones  form  a  line 
sufficiently  straight  to  be  traversed  by  the  knife 
in  one  cut  when  once  the  blade  has  been  introduced. 


a 

Fig.  77. -Amputation  of  Great  Toe,  with  its  Metatarsal  Bone  (Agatz). 

a,  Internal  cuneiform  hone  ;  b,  adductor  pollicis  :  c,  extensor  longus  pollicis; 
■1.  flexor  longus  poldcis  ;  e,  plantar  branch  of  dorsalie  pedis  artery. 

The  joint  also  between  the  first  metatarsal  and 
internal  cuneiform  bones  is  in  a  straight  hue  and  readily 
opened.  The  most  difficult  part  of  the  disarticulation 
concerns  the  separation  of  the  second  metatarsal  bone, 
which  is  deeply  lodged  between  the  tarsal  segments. 
The  chief  bond  of  union  between  this  bone  and  the 
tarsus  is  effected  by  a  strong  interosseous  ligament 
that  passes  between  it  and  the  internal  cuneiform. 
In  Fig.  76  the  knife  is  placed  in  the  position  required 
to  divide  that  ligament. 

In  the  subastragaloid  amputations  a  dis- 
articulation  is  effected  at  the  astragalo-scaphoid  -  and 


\2! 


2 


\   4 


5  \ 


vll 


/  7 


6\   i 


":  8 


10 


nVte- 


Fig.  78. --Cutaneous  Nerve-Supply  of  Lower  Limb. 
A.  iterior  Aspect.— I,  Ilio-inguinal ;  2,  genito-crural ;  3,  external  cutaneous  ;  4,  middle 
cutaneous  ;  5,  internal  cutaneous;  6,  patellar  plexus  ;  7,  branches  of  external 
,,  popliteal  ;  8,  internal  saphenous;  9,  musculo- cutaneous;  10,  external  saphe- 
"*    nous  ;  11,  anterior  tibial. 

Posterior  Aspect.-^,  2,  and  3,  small  sciatic;  4,  external  cutaneous:  5,  internal 
cutaneous;  6,  internal  saphenous;  7,  branches  of  external  popliteal ;  8,  short 
saphenous;  9,  posterior  tibial;  10,  internal  saphenous;  11,  internal  plantar; 
12.  external  plantar. 


Chap,  xxiii.]      The  Ankle  and  Foot.  533 

astragalo-calcaneal  joints.  The  astragalus  is  the  only 
bone  of  the  foot  left  behind,  and  forms  the  summit  of 
the  stump. 

Fig.  77  shows  the  position  of  the  more  important 
structures  that  are  divided  in  amputation  of  the  great 
toe  together  with  its  metatarsal  bone. 

The  nerve  supply  of  the  lower  limb. — In 
Fig.  78  is  shown  the  cutaneous  nerve-supply  of  the 
inferior  extremities  on  both  the  anterior  and  the  posterior 
aspect,  and  in  Fig.  79  are  seen  the  cord  segments  from 
which  they  are  derived.  Paralyses  of  the  lower  limbs  are 
common,  but  are  more  often  due  to  some  lesion  in  the 
inferior  segment  of  the  cord  than  to  damage  received 
by  any  one  individual  nerve.  Cases,  however,  are 
recorded  where  a  single  trunk  has  been  injured  and  a 
limited  form  of  paralysis  has  followed  in  consequence. 

Paralysis  of  the  anterior  erural  nerve 
has  been  caused  by  injuries  to  the  lower  part  of  the 
vertebral  column  implicating  the  cauda  equina,  by 
fractures  of  the  pelvis,  by  tumours  of  the  pelvis,  by 
psoas  abscess,  by  fractures  and  dislocations  of  the  femur, 
and  by  stabs  in  the  region  of  the  groin.  In  this  nerve 
lesion  the  patient  is  unable  to  flex  the  hip  and  to  raise 
the  body  from  the  recumbent  position  (ilio-psoas).  The 
power  of  extending  the  leg  at  the  knee  is  lost  (quadriceps 
extensor  cruris)  ;  the  function  of  the  sartorius  is  destroyed 
and  that  of  the  pectineus  impaired.  Sensation  is 
impaired  in  parts  supplied  by  the  internal  and  middle 
cutaneous  nerves  and  the  long  saphenous  nerve. 

Para  lysis  of  the  obturator  nerve  alone  is  a 
rare  condition,  although  it  may  be  found  associated 
with  a  like  lesion  of  the  preceding  trunk.  It  may  lie 
brought  about  by  the  pressure  exercised  upon  the  nerve 
in  cases  of  obturator  hernia  and  by  the  foetal  head 
dining  delivery.  The  muscles  implicated  are  the 
adductors,  gracilis,  pectineus,  and  external  obturator. 
The  patient  is  unable  to  press  the  knees  together,  or 
to  cross  the  legs.  Rotation  outwards  is  difficult,  and 
sensation  is  affected  in  the  skin  supplied. 

Paralysis  of  the  internal  popliteal  nerve. 


Fig.179  -Showing  the  Skin  Areas  in  the  Lower  Extremity  supplied  bv  the 
Lumbar  and  Sacral  Segments  of  the  Spinal  Cord.    &S?Head  ) 

°n?h?n^^SKSS^^tSCOrd  *™**tf***i    For 


chap,  xxiii.]       The  Ankle  and  Foot.  535 

— There  is  inability  to  extend  the  ankle  and  to  flex  the 
toes  (flexor  longus  digitorum,  flexor  propriua  pollicis, 
tibialis  posticus,  gastrocnemius,  and  soleusj.  The 
patient  is  unable  to  stand  upon  the  toes,  owing  to  loss 
of  function  in  the  two  last-named  muscles.  The  power 
of  adducting  the  foot  and  of  raising  its  inner  border 
is  impaired  (tibialis  posticus),  and  lateral  movement 
in  the  toes  is  lost  owing  to  paralysis  of  all  the  small 
muscles  of  the  sole.  Sensation  is  impaired  over  the 
plantar  aspect  of  the  toes,  the  sole,  and  in  part  of 
the  lower  half  of  the  back  of  the  leg. 

In  paralysis  of  the  external  popliteal  nerve 
the  action  of  the  muscles  on  the  front  of  the  leg  is  lost. 
The  foot  hangs  down  and  the  toes  catch  the  ground 
in  walking.  The  foot  can  be  neither  flexed  nor  abducted 
(extensor  communis  digitorum,  extensor  proprius 
pollicis,  peroneal  muscles).  Adduction  is  imperfect, 
owing  to  paralysis  of  the  tibialis  anticus.  Extension 
of  the  toes  is  only  possible  to  the  slight  extent  effected 
by  the  interossei.  The  arch  of  the  foot  becomes  flattened 
owing  to  loss  of  the  support  furnished  by  the  peroneus 
longus.  Sensation  is  impaired  over  the  front  and 
outer  side  of  the  leg  and  on  the  dorsum  of  the  foot, 
and  also  over  some  part  of  the  back  of  the  leg,  owing 
to  paralysis  of  the  communicans  peronei. 

When  the  great  seiatie  nerve  is  paralysed 
there  will  be,  in  addition  to  the  loss  of  function  in  the 
two  preceding  nerves,  an  inability  to  flex  the  knee 
owing  to  paralysis  of  the  hamstrings,  while  rotation 
of  the  limb  may  be  impaired  by  loss  of  power  in  the 
quadratus  femoris  and  obturator  interims. 

A  knowledge  of  the  segments  of  the  eord  from 
Avliieli  the  nerves  of  the  lower  limb  arise  often 
assists  the  surgeon  in  localising  certain  lesions.  Section 
of  a  nerve  root,  as  may  happen  in  fracture  of  the  spine, 
or  destruction  of  its  centre  in  the  spinal  cord,  gives  rise 
to  paralysis  in  a  definite  group  of  muscles  and  anaesthesia 
of  a  certain  area  of  skin.  The  skin  areas  supplied  by 
the  lumbar  and  sacral  segments  are  shown  in  Fig.  79, 
and   these   segments,   according  to  Kocher,   innervate 


536  Surgical  Applied  A n atomy.  [Chap.  xxm. 

the  following  groups  of  muscles :  Third  lumbar,  the 
psoas,  iliacus,  pectineus,  sartorius  and  adductors ; 
fourth  lumbar,  quadriceps  extensor  cruris ;  fifth 
lumbar,  gluteus  medius  and  minimus,  tensor  vaginae 
femoris  and  hamstrings  ;  first  sacral,  gluteus  maximus, 
short  external  rotators  of  hip-joint,  peronei,  extensors 
of  toes  and  flexors  of  ankle  ;  second  sacral  gastro- 
cnemius soleus,  long  flexors  of  toes  and  extensors  of 
the  ankle-joint  and  muscles  of  the  sole. 


537 


Part  Vh 

CHAPTER  XXIV. 

THE    SriNE. 

The  vertebral  column  combines  in  a  remarkable 
way  many  very  different  and  complicated  functions. 
It  acts  as  the  central  pillar  of  the  body,  and  as  the  column 
that  supports  the  weight  of  the  head.  It  connects 
the  upper  and  lower  segments  of  the  trunk.  It  gives 
attachments  to  the  ribs.  It  has  the  property  of  miti- 
gating the  effects  of  shocks  that  are  transmitted  from 
various  parts  of  the  body.  It  permits,  to  a  wonderful 
degree,  of  a  number  of  most  complicated  movements  ; 
and,  lastly,  forms  a  solid  tube  for  the  reception  of  the 
spinal  cord. 

It  owes  much  of  its  elasticity,  and  of  its  power  of 
breaking  up  divers  forces  communicated  to  it,  to  its 
curves.  Of  the  four  curves,  two,  the  dorsal  and  sacral, 
are  primary,  are  due  to  the  formation  of  the  thoracic 
and  pelvic  cavities,  and  depend  mainly  upon  the  shape 
of  the  bones.  The  other  two,  the  cervical  and  lumbar, 
are  compensatory  curves,  and  depend  mainly  upon 
the  shape  of  the  intervertebral  discs.  The  dorsal  and 
sacral  curves  appear  in  fcetal  life  ;  the  lumbar  and 
cervical  curves  appear  after  birth,  and  depend  on  the 
assumption  of  the  erect  position.  The  infant's  spine 
appears  straight.  The  only  marked  curve  seen  in  the 
back  of  the  young  child  is  a  general  curving  of  the 
column  backwards,  a  kyphosis.  When  the  infant  is 
first  encouraged  to  sit  erect,  this  is  the  outline  assumed 
by  the  spine,  and  in  some  weakly  children,  and 
especially  in  those  afflicted  with  rickets,  this  curvature 
is  often  very  pronounced.     The  discs  are  twenty-three 


538  Surgical  Applied  Anatomy.  [Chap.  xxiv. 

in  number  and  make  up  nearly  one-fourth  of  the  entire 
length  of  the  spine.  If  the  discs  be  removed,  and  the 
vertebrae  be  articulated  in  the  dry  state,  the  cervical 
and  lumbar  convexities  almost  disappear,  and  the 
column  tends  to  present  one  great  curvature,  the  con- 
cavity of  which  is  forwards,  and  the  most  marked  part 
of  which  corresponds  to  a  point  just  below  the  middle 
of  the  dorsal  region.  This  somewhat  resembles  the 
curve  seen  in  the  spines  of  the  aged,  and  in  such 
individuals  it  may  be  to  no  small  extent  due  to  the 
shrinking  of  the  intervertebral  discs. 

It  is  by  means  of  the  discs  that  the  movements 
of  the  spine  are  in  the  main  permitted,  and  it  will  be 
found  that  they  are  most  developed  in  regions  where 
most  movement  is  allowed.  They  act  also  as  springs 
in  giving  elasticity  to  the  column,  and  in  economising 
muscular  action,  while  at  the  same  time  they  play  the 
part  of  buffers  in  modifying  the  effect  of  shocks  trans- 
mitted along  the  spine. 

Although  the  motion  permitted  between  any  two 
individual  vertebrae  is  not  extensive,  yet  the  degree  of 
movement  capable  of  being  exercised  in  the  column 
as  a  whole  is  considerable.  This  movement  is  least 
free  at  the  dorsal  region,  and  is  most  extensive  in  the 
neck  and  loins.  In  the  lumbar  region  (the  base  of 
the  column)  exists  the  greatest  degree  of  motion  per- 
mitted in  the  spine,  and  here  is  allowed,  not  only  for- 
ward and  backward  flexion,  but  also  lateral  bending, 
and  a  certain  amount  of  rotation.  In  the  cervical  region 
flexion  in  the  antero-posterior  direction  is  not  so  ready 
as  it  is  in  the  loins,  although  the  neck  enjoys  the  greatest 
degree  of  rotation  and  of  lateral  flexion. 

Scoliosis.— In  very  few  people  do  the  spines  of.  the 
vertebrae  lie  in  a  perfectly  straight  line  down  the  back. 
There  is  commonly  a  slight  degree  of  lateral  curvature. 
If  the  pelvis  be  tilted  laterally,  as  when  the  limbs  are 
unequal  in  length,  a  compensatory  lateral  curve  is  pro- 
duced. In  scoliosis,  lateral  curvature  is  combined  with 
a  rotation  of  the  vertebrae,  the  spinous  processes  turning 
to  one  side  of    the  median  line  and  the  bodies  to  the 


chap,  xxiv.j  The  Spine.  539 

opposite.  It  is  a  disease  of  adolescents,  due  to  a  weakness 
of  the  spinal  muscles,  which  are  unable  to  maintain 
the  vertebrae  in  the  position  necessary  for  the  erect 
posture.  Each  vertebra  is  provided  with  three  levers, 
a  posterior  (the  spinous  process)  and  two  lateral  (the 
transverse  processes  and  attached  rib).  The  erector 
spinas  acts  on  the  lateral  levers  ;  the  multifidus  spinas 
and  muscles  for  the  upper  extremity  on  the  posterior. 
It  is  through  training  these  muscles  by  suitable 
exercises  that  the  vertebras  can  be  restored  to,  and 
maintained  in,  their  normal  positions. 

Sprains  of  the  vertebral  column. — The  many 
joints  and  ligaments  of  the  part,  and  the  varied  and 
violent  movements  to  which  it  may  be  exposed,  render 
it  very  liable  to  be  the  seat  of  sprains.  These  injuries, 
however,  cannot  reach  any  great  magnitude,  for  so 
closely  are  the  individual  vertebra?  articulated,  that 
any  force  severe  enough  to  produce  other  than  slight 
tearing  of  the  ligaments  will  tend  to  cause  a  fracture 
or  dislocation  of  the  bones. 

Sprains  are  most  commonly  met  with  in  the  cervical 
and  lumbar  segments  of  the  spine.  This  localisation 
is  due  to  the  mobility  of  those  parts,  and  to  their  ten- 
dency to  diffuse  any  violence  transmitted  to  them, 
and  so  to  render  it  more  general.  For  it  is  to  be  noted 
that  the  more  localised  an  injury,  the  more  likely  it  is 
to  produce  a  fracture  or  dislocation  rather  than  a  sprain. 

In  the  cervical  region,  also,  the  tendency  to  sprain 
is  increased  by  the  near  articulation  of  the  column 
with  the  head,  and  the  possibility  of  any  violence  applied 
to  the  skull  being  transmitted  to  the  spine. 

Sprains  of  the  spine  are  not  apt  to  be  associated 
with  the  external  evidences  of  ecchymosis,  since  be- 
tween the  skin  and  the  column  there  intervene  not 
only  many  layers  of  muscles,  but  also  dense  expansions 
of  fascia. 

It  has  already  been  pointed  out  that  sprains  in  the 
loin,  produced  by  severe  bending  forwards  of  the  column, 
may  be  associated  with  some  damage  to  the  kidney 
and  consequent  hematuria  (page  362). 


.~54°  Surgical  Applied  Anatomy.  [Chap.  xxiv. 

A  sprained  back  is  often  the  seat  of  a  considerable 
degree  of  pain  and  stiffness,  that  persists  long  after 
the  immediate  effects  of  the  lesion  must  have  passed 
away.  Such  a  condition  may  be  understood  by  noticing 
that  the  column  presents  a  vast  number  of  separate 
articulations,  each  provided  with  cartilage,  synovial 
membrane,  and  capsular  ligaments.  These  joints  have 
no  qualities  that  exempt  them  from  the  common  evils 
incident  to  sprains  of  more  superficial  articulations  ; 
and  there  is  little  doubt  that  the  long-felt  pain  and 
inconvenience  often  depend  upon  some  synovitis  of 
the  vertebral  joints.  In  a  few  cases  this  synovitis  has 
gone  on  to  suppuration,  and  in  one  instance  at  least 
the  pus  so  formed  found  its  way  into  the  spinal  canal 
and  induced  some  mischief  in  the  cord. 

Fractures  and  dislocations  of  the  spine.— 
The  effects  of  violence  applied  to  the  column  are  much 
diminished  by  the  general  elasticity  of  the  spine,  by  its 
curves,  and  by  the  circumstance  that  it  is  composed  of 
a  number  of  separate  segments.  Each  vertebra  meets 
the  one  immediately  above  or  below  it  at  three  points 
of  contact,  the  body  and  the  two  articulating  processes. 
The  bodies  are  separated  by  the  inter-vertebral  disc, 
which  acts  as  an  excellent  spring  or  buffer  in  modifying 
the  effects  of  violence.  The  articulating  processes  are 
more  or  less  wedge-shaped,  the  thin  edge  of  one  being 
applied  to  the  base  of  the  other.  When  a  force  is  applied 
to  the  column  that  tends  to  compress  the  vertebrae 
together,  the  bases  of  the  two  wedges  are  brought  in 
more  and  more  close  relation,  and  thus  an  increasing 
resistance  is  offered  to  the  compressing  power. 

The  parts  of  the  spine  most  liable  to  injury  are  (l) 
the  atlo-axial ;  (2)  the  cervico-dorsal ;  and  (3)  the 
dorso-lumbar.  In  the  atlo-axial  region  the  parts  not 
only  enjoy  a  very  considerable  degree  of  movement 
but  are  very  directly  influenced  by  many  forms  of 
violence  applied  to  the  head.  In  the  two  other  regions 
it  will  be  noted  that  a  flexible  part  of  the  spine  joins  a 
comparatively  rigid  segment  of  it,  and  thus  violence 
applied  to  the  column  in  either  of  these  districts  is  apt 


chap,  xx rv.]  The  Spine.  541 

to  be  concentrated  rather  than  diffused.  The  sternum 
and  .ribs  act  as  a  splint  to  the  dorsal  part  of  the  column. 
The  mechanism  is  in  a  way  illustrated  by  the  circum- 
stance that  a  fishing-rod  when  it  snaps  commonly  breaks 
near  a  joint,  that  is  to  say,  at  a  spot  where  a  flexible 
segment  of  the  rod  meets  a  less  elastic  portion.  In  the 
dorso-lumbar  region,  moreover,  the  vertebras,  although 
they  have  to  support  almost  as  much  weight  as  have 
those  of  the  lumbar  region  proper,  are  yet  dispropor- 
tionately small  in  size.  Being  placed,  also,  near  the 
middle  of  the  column,  they  can  be  influenced  on  all 
sides  by  a  powerful  amount  of  leverage.  The  gravity 
of  all  injuries  to  the  spine  depends  upon  the  risk  of 
damage  to  the  cord  enclosed  in  the  column.  Apart 
from  this  complication,  fractures  and  dislocations  in 
this  region  are  apt  to  do  well,  and  if  the  patient  survive, 
the  former  lesions  nearly  always  heal  readily. 

The  position  of  the  cord  within  the  vertebral  canal 
and  the  arrangement  of  its  membranes  are  such  that 
it  presents  many  facilities  for  escaping  injury  from 
violence.  These  will  be  dealt  with  subsequently  in 
speaking  of  the  cord  itself.  It  may,  however,  be  noted 
here  that  the  construction  of  the  vertebra?,  and  their 
relation  to  one  another,  are  of  a  character  to  afford  much 
protection  to  the  cord,  even  in  cases  where  they  them- 
selves are  extensively  damaged.  "  Being  lodged  in  the 
centre  of  the  column,  it  (the  cord)  occupies  neutral  ground 
to  forces  which  might  cause  fracture.  For  it  is  a  law  in 
mechanics  that  wThen  a  beam,  as  of  timber,  is  exposed  to 
breakage,  and  the  force  does  not  exceed  the  limits  of  the 
strength  of  the  material,  one  division  resists  compression, 
another  laceration  of  the  particles,  while  the  third, 
between  the  two,  is  in  a  negative  condition."  (Jacobson, 
Holmes'  "  System.")  Now,  it  happens  that  fractures 
of  the  spine  are  most  often  due  to  violence  that  bends 
the  column  forwards.  The  anterior  segment,  in  such  a 
case,  will  be  subject  to  compression,  the  posterior  to 
laceration,  and  the  intermediate  portion  will  be  in  a 
neutral  condition.  When  the  spine  is  examined,  it  will 
be  found  that  its  anterior  part,  composed  of  the  large 


542  Surgical  Applied  Anatomy.  [Chap.  xxiv. 

cancellous  bodies,  is  excellently  adapted  to  resist  the 
effects  of  compression,  while  its  posterior  parts,  com- 
posed of  slighter  and  more  compact  bones  and  surrounded 
by  many  strong  ligaments,  are  well  arranged  to  resist 
the  effects  of  a  tearing  force.  The  spinal  cord,  situated 
between  these  two  divisions,  occupies  the  position  of 
least  danger. 

The  vertebrae  may  be  fractured  without  being  dis- 
located, but  a  dislocation  without  a  fracture  is  rarely 
possible. 

It  would  appear,  indeed,  that  a  luxation  of  the 
spine,  with  no  fracture  of  the  bone,  cannot  occur  in  either 
the  dorsal  or  lumbar  regions.  Mr.  Jacobson,  in  the 
essay  above  referred  to,  writes :  "  I  believe  I  am  correct 
in  stating  that  there  is  no  case  recorded,  and  thoroughly 
verified,  in  recent  years,  of  dislocation  of  the  lumbar 
or  dorsal  vertebras  unaccompanied  with  any  fracture 
of  the  body,  transverse  or  articular  processes."  Dislo- 
cation without  fracture  has  been  met  with  in  the 
cervical  spine,  although  even  there,  if  we  except 
the  first  two  vertebras,  it  is  very  rare.  When  it  occurs 
it  most  often  involves  the  fifth  vertebra,  which,  with 
the  rest  of  the  column  above  it,  is  displaced  forwards 
and  downwards.  Luxations  in  other  directions  have 
been  noted,  but  they  are  extremely  uncommon.  The 
possibility  of  luxation  in  the  cervical  region  without 
dislocation  is  explained  by  the  small  size  of  the  vertebral 
bodies,  the  obliquity  of  their  articular  processes,  and  the 
relatively  slight  opposition  they  offer  to  displacement 
when  compared  with  like  processes  in  the  other  parts 
of  the  column.  The  luxation  is  usually  bilateral  and 
incomplete,  and  the  result  of  a  forcible  bending  of  the 
head  and  upper  part  of  the  spine  forwards  and  down- 
wards. When  situated  high  up  the  displacement  may 
be  appreciated  by  an  examination  of  the  part  through 
the  pharynx.  In  the  complete  bilateral  dislocation 
the  cord  is  usually  hopelessly  crushed.  These  luxations 
have  been  reduced  by  forcible  extension,  although  the 
circumstances  under  which  such  a  procedure  is  advisable 
are  neither  frequent  nor  very  distinctly  marked. 


Chap,  xxiv.]  The  Sp/ae.  543 

Since,  in  severe  injuries,  dislocation  and  fracture 
are  so  usually  associated,  it  is  common  to  deal  with 
these  lesions  under  the  title  of  "fracture-dislocation." 

Fracture-dislocation  may  be  due  to  (1)  indirect, 
or  (2)  direct  violence.  1.  The  injuries  from  indirect 
violence  are  by  far  the  more  common.  They  are  due 
to  a  violent  bending  of  the  head,  or  of  the  spine  above 
the  seat  of  lesion,  forwards  and  downwards.  Thus, 
the  cervical  spine  has  been  more  than  once  broken  by  a 
"  header  "  into  shallow  water  ;  while  the  dorsal  vertebrae 
have  been  fractured  and  displaced  by  the  acute  bending 
of  the  column,  produced  by  a  heavy  sack  falling  upon 
the  back  of  the  neck. 

This  form  of  injury  is  most  commonly  met  with  in 
the  cervical  and  upper  dorsal  regions.  These  parts  of 
the  column  possess  great  mobility,  the  bodies  that 
compose  them  are  not  large,  and  are  influenced  by 
violence  applied  to  the  head.  In  a  well-marked  case 
there  is  some  crushing  of  the  vertebrae  involved,  and 
the  usual  deformity  depends  upon  the  sliding  of  the 
centrum  above  downwards  and  forwards  upon  the 
centrum  below.  Complete  displacement  of  any  two 
vertebra?  from  one  another  is  prevented  by  a  locking 
of  the  posterior  processes.  In  some  cases  the  luxation 
is  complete,  a  condition  that  is  least  frequently  met 
with  in  the  lumbar  spine. 

In  the  cervical  and  dorsal  regions,  the  parts,  after 
the  dislocation,  may  often  be  returned  to  their  normal 
position  ;  but  in  the  loins  this  replacement  is  usually 
impossible,  owing  to  the  locking  of  the  large  and 
powerful  articular  processes.  In  the  neck  the  lamina? 
and  spines  may  be  fractured,  while  the  articulating 
processes,  being  broad  and  nearly  horizontal,  usually 
escape,  even  when  there  is  much  displacement  of  the 
parts.  In  the  dorsal  spine  the  lamina?  and  articular 
processes  are  always  torn  when  displacement  occurs. 
In  the  lumbar  region  the  articular  processes  usually 
escape  fracture,  although  they  are  violently  torn 
asunder.  In  all  cases  there  is  more  or  less  laceration 
of    the    intervertebral    discs,    the    supraspinous,    inter- 


544  Surgical  Applied  Anatomy.  [Chap.  xxiv. 

spinous,  and  capsular  ligaments  are  torn,  as  are  also 
the  ligamenta  subflava.  When  the  bodies  are  much 
crushed  and  displaced  the  anterior  and  posterior  common 
ligaments  are  commonly  ruptured. 

2.  In  the  fracture-dislocations  due  to  direct  violence 
the  lesion  may  be  at  any  part  of  the  spine.  Some  form 
of  direct  violence  is  applied  to  the  back,  and  the  column 
tends  to  become  bent  backwards  at  the  spot  struck. 
In  the  previous  class  of  injuries  it  will  be  noted  that 
the  anterior  segments  of  the  vertebrae  suffer  compression, 
while  the  posterior  suffer  from  the  effects  of  laceration 
and  a  tearing  asunder  of  their  parts.  In  lesions  due 
to  direct  violence  the  circumstances  of  the  injury  are 
reversed,  the  posterior  segments  tend  to  be  crushed 
together,  while  the  bodies  on  the  front  of  the  spine 
are  separated. 

Much  displacement  is  very  rarely  met  with  in  this 
form  of  accident.  To  produce  separation  of  the  ver- 
tebrae the  violence  must  be  very  extreme,  and  as  a 
rule  the  force  expends  itself  upon  a  crushing  of  the 
hinder  portions  of  the  spinal  segments.  It  follows 
from  this,  also,  that  injury  to  the  cord  is  less  common 
and  less  severe  in  lesions  due  to  direct  violence  than 
in  those  due  to  indirect  violence.  In  the  atlo-axial 
region  the  atlas  and  occipital  bone  have  been  dislocated 
from  one  another  by  direct  violence,  although  the  most 
frequent  lesion  is  a  dislocation  of  the  former  forwards 
upon  the  axis,  a  lesion  usually,  if  not  always,  associated 
with  fracture  of  the  odontoid  process. 

The  spinous  processes  may  be  broken  off  as  a  result 
of  well-localised  blows.  The  prominent  spines  in  the 
lower  cervical  region  and  the  long  processes  of  the  dorsal 
tract  of  the  column  are  those  that  usually  suffer.  The 
lumbar  spines  are  less  frequently  broken,  being  com- 
paratively small  and  well  protected  by  the  great  muscles 
of  the  back. 

The  transverse  processes  and  laminae  can  scarcely 
be  fractured  alone. 

In  several  instances  of  fracture-dislocation  and  of 
fracture  alone  the  spine  has  been  trephined,  or  rather 


Chap,  xx i\.  The  Spine.  545 

portions  of  the  Laminae  and  spinous  processes  have 
been  resected  {laminectomy).  By  this  means  the 
spinal  canal  has  been  freely  opened  up,  effused  blood 
has  been  allowed  to  escape,  and  the  cord  has  been  freed 
from  pressure.  The  laminae  are  divided  as  near  the 
transverse  process  as  possible,  and  the  tough  ligamenta 
subflava  require  careful  division.  Dr.  White,  of  Phila- 
delphia, has  collected  (1889)  thirteen  recent  examples 
of  operation  for  fracture  with  only  one  death. 

The  column  is  reached  through  a  median  incision, 
and  the  great  muscular  masses  are  cleared  from  the 
spinous  processes  and  lamina?  on  either  side.  The 
wound  being  nearly  median,  the  bleeding  is  not  excessive. 
The  dorsal  spinal  plexus  of  veins  lies,  along  the  spines 
and  over  the  lamina?.  On  the  deep  surface  of  these 
veins  lie  the  posterior  longitudinal  spinal  veins.' 

This  operation  has  also  been  carried  out  with  success 
in  cases  of  paralysis  due  to  the  pressure  upon  the  cord 
by  displaced  bone  or  inflammatory  exudations  in  caries 
of  the  spine  (Pott's  disease).  It  has  to  be  noted,  how- 
ever, in  the  last-named  class  of  case,  that  the  condition 
exhibits  a  tendency  to  spontaneous  cure. 

The  spinal  cord  is  in  the  adult  about  IS  inches 
in  length,  and  extends  from  the  lower  margin  of  the 
foramen  magnum  to  the  lower  edge  of  the  body  of  the 
first  lumbar  vertebra.  In  some  cases  it  ends  at  the 
second  lumbar,  and  in  other  instances  at  the  last  dorsal 
vertebra.  It  is  to  be  noted  also  that  in  flexion  of  the 
spine  the  cord  is  a  little  raised.  When  the  body  is  bent 
and  the  arms  stretched  out  the  lumbar  part  is  raised 
LO  mm.  In  the  earlier  months  of  foetal  life  the  medulla 
spinalis  occupies  the  whole  length  of  the  vertebral  canal, 
but  after  the  third  month  the  canal  and  lumbar  and 
sacral  nerves  grow  so  much  faster  than  does  the  cord 
itself,  that  by  the  time  of  birth  it  reaches  no  farther  than 
the  third  lumbar  vertebra.  It  is  obviously  a  great 
advantage,  in  cases  of  injury,  that  the  spinal  cord 
does  not  occupy  that  part  of  the  vertebral  pillar  which 
joins  the  base  of  the  column,  and  which  permits  not 
only  of  considerable   movement,   but  is  liable  also  to 


;46 


Surgical  Applied  Anatomy,  rchap.  xxiv. 


frequent  wrenches  and  strains.  It  is  important  to 
recollect  that  although  the  cord  itself  ends  at  the  spot 
indicated,  the  dura  mater,  the  arachnoid,  and  the 
collection  of  cerebro-spinal  fluid  extend  as  far  as  the 
second  piece  of  the  sacrum.  Injuries  inflicted,  therefore, 
upon  the  spine  as  low  down  as  this  latter  point  may 
cause  death  by  inducing  inflammation  of  the  meninges. 


A..Div. 


t.Art. 


Fig.  SO.— Section  through  Spinal  Cord,  Membranes,  and  Spinal  Canal. 

a.r.,  at  origin  of  anterior  root;  p.b.,  at  origin  of  posterior  root;  s.p.,  septum 
posticum  ;  p.m.,  pia  mater ;  l.d.,  ligamentum  denticulatuin  ;  the  arachnoid 
(arach.),  dura  mater  (dura  m.i,  and  sub-arachnoid  space  are  shown. 


The  cord  in  the  dorsal  region  measures  about  10  mm. 
from  side  to  side,  and  8  mm.  in  the  antero-posterior 
direction.  The  cervical  enlargement  is  largest  opposite 
the  fifth  or  sixth  cervical  vertebrae,  where  it  measures 
about  13  mm.  from  side  to  side.  The  greatest  part  of 
the  lumbar  enlargement  is  opposite  the  twelfth  dorsal 
vertebra,  where  its  lateral  measurement  is  about  12  mm. 
The  spinal  dura  mater  is  a  strong  and  substantial 
membrane,  and  between  it  and  the  walls  of  the  ver- 


Chap,  xxiv.]  The  Spine.  547 

tebral  canal  a  considerable  space  exists  occupied  by 
loose  areolar  tissue  and  a  plexus  of  veins  (Fig.  80).  It 
is  tough,  and  may  remain  undamaged  when  the  cord 
is  completely  severed  by  a  crushing  force.  It  will  be 
readily  understood  that  injury  and  inflammation  of 
the  meninges,  as  results  of  lesions  applied  to  the  spine, 
are  much  less  frequent  than  are  like  complications 
after  injuries  to  the  skull.  The  looseness  of  the  spinal 
dura  mater,  its  freedom  from  any  but  slight  and  occasional 
attachments  to  the  bone,  and  the  space  around  it  in 
which  effusions  can  extend  with  little  possibility  of 
becoming  limited,  will  explain  the  rarity  in  the  spine 
of  those  complications  which  follow  upon  depressed 
bone  and  extravasations  of  pus  and  blood  in  connection 
with  the  dura  mater  within  the  skull.  The  plexus 
of  thin-walled  veins  that  occupies  the  interval  between 
the  theca  and  the  bones  may  prove  a  source  of  extensive 
haemorrhage  in  cases  of  injury  to  the  column.  The 
blood  so  poured  out  tends  to  gravitate  to  the  lowest 
part  of  the  canal,  and  when  sufficient  in  quantity  may 
produce  pressure  effects  upon  the  medulla  spinalis. 

Over  the  arches  at  the  posterior  aspect  of  the  ver- 
tebra? is  situate  a  plexus  of  vessels  (the  dorsal  spinal 
veins)  that  receives  blood  from  the  muscles  and  integu- 
ments of  the  back.  These  vessels  communicate  through 
the  ligamenta  subflava  with  the  venous  plexuses  within 
the  spinal  canal,  and  by  means  of  this  communication 
inflammation  from  without  may  be  conducted  to  the 
theca  of  the  cord.  Thus  spinal  meningitis  has  followed 
upon  deep  bed-sores,  and  upon  suppurative  affections 
situated  in  the  immediate  vicinity  of  the  spinal  laminae. 

Within  the  dura  mater  are  two  spaces,  the  sub- 
dural and  the  subarachnoid,  as  in  the  skull.  The 
arachnoid  is  closely  applied  to  the  dura  mater,  the 
subdural  being  merely  a  potential  space,  while  the 
subarachnoid  is  extensive  and  occupied  by  cerebro- 
spinal fluid,  which  surrounds  the  cord  and  is  continuous 
with  the  great  subarachnoid  spaces  at  the  base  of  the 
brain  (Fig.  SO).  By  means  of  this  open  communication 
inflammatory  affections   may  readily  spread   from   the 


548  Surgical  Applied  Anatomy.  [Chap. xxiv. 

cord  to  the  brain.  Into  these  spaces  blood  may  be 
extravasated  in  cases  of  injury.  Instances  have  been 
recorded  where  the  theca  has  been  opened  by  a  wound, 
and  the  cerebro-spinal  fluid  has  escaped  in  large  quantities. 
The  fluid  normally  contains  "05  per  cent,  of  albumen, 
but  if  the  membranes  are  inflamed  the  percentage  is 
double  that  amount.  In  certain  conditions  the  pressure 
of  the  fluid  may  rise  to  such  an  extent  as  to  cause  death. 
In  normal  conditions  the  fluid  is  absorbed  at  any  pressure 
above  that  of  the  surrounding  veins  (Hill).  In  the 
recumbent  posture  the  pressure  should  support  a  column 
of  water  2  inches  high.  In  disease  it  may  rise  to  ten 
times  that  amount.  The  pressure  may  be  relieved 
by  a  lumbar  puncture,  made  by  thrusting  a  needle 
8-10  cm.  long  into  the  subarachnoid  space  in  the 
lumbar  region  of  the  spine.  A  point  is  selected  between 
the  third  and  fourth  lumbar  spines,  \  an  inch  from 
the  middle  line.  The  needle  perforates  the  ligamentum 
subflavum  between  the  laminse.  Convulsions  follow  if 
the  pressure  be  reduced  much  below  the  normal.  At 
this  level  the  cord  cannot  be  injured,  but  the  needle 
may  pierce  one  of  the  lower  nerve  roots,  giving  rise 
to  twitching  in  some  of  the  muscles  of  the  lower 
extremity. 

The  position  of  the  cord  is  such  that  it  is  not  readily 
reached  in  incised  and  punctured  ivounds.  The  only 
spots  at  which  it  is  easy  of  access  are  the  intervals  between 
the  atlas  and  occiput  and  the  atlas  and  axis.  Many 
cases  have  been  recorded  of  fatal  wound  of  the  cord 
in  these  positions.  Lower  down  in  the  column  the 
medulla  spinalis  may  be  reached  if  the  wound  have 
a  certain  direction.  Thus  a  case  is  reported  where  a 
pointed  body  entered  the  canal  between  the  ninth  and 
tenth  dorsal  vertebra?,  having  been  introduced  from 
below  upwards. 

Several  examples  of  damage  to  the  cord  by  sword 
or  bayonet  wounds  have  been  put  on  record,  but  in 
most  of  these  instances  the  wound  was  associated  with 
some  fracture  of  the  protecting  bone. 

The  pia  mater  forms  a  strengthening  sheath  for  the 


Chap,  xxiv.]  The  Spine.  549 

co?d.  On  it  the  arteries  ramify  before  entering  to 
supply  its  substance.  The  vertebral,  intercostal  lumbar, 
ilio -lumbar,  and  lateral  sacral  arteries  send  twigs  along 
the  nerve  roots  to  the  cord. 

< aissiou  of  the  cord. — After  certain  injuries 

to  the  back  a  train  of  symptoms,  usually  of  a  severe 
and  complicated  character,  has  been  described,  which 
has  been  assigned  to  a  concussion  or  shaking  of  the 
spinal  cord. 

In  these  injuries  it  is  assumed  that,  as  a  result  of 
a  sudden  shock  transmitted  to  it,  the  cord  undergoes 
certain  molecular  changes,  which  lead  to  a  more  or 
less  severe  disturbance  of  its  function.  The  condition 
has  been  compared  to  concussion  of  the  brain,  although 
it  must  be  owned  that  the  symptoms  often  accredited 
to  concussion  of  the  cord  have  a  character  more  complex 
than  that  seen  in  like  lesions  of  the  more  complex  organ. 

A  great  many  surgeons  are  inclined  to  dispute  the 
existence  of  this  lesion,  or  rather  decline  to  recognise 
the  connection  between  a  certain  train  of  symptoms 
and  a  simple  molecular  disturbance  of  the  cord.  It  is 
very  probable  that  in  many  of  the  reputed  instances  of 
cord-concussion  the  symptoms  (if  we  except  such  as 
are  assumed  and  such  as  depend  upon  changes  in  the 
brain)  are  due  to  a  more  distinct  damage  to  the  medulla 
spinalis,  to  haemorrhages,  to  pressure,  and  to  other 
gross  changes.  Without  entering  into  any  discussion 
upon  the  subject,  it  may  be  sufficient  to  point  out  some 
of  the  anatomical  objections  that  appear  to  oppose 
themselves  to  the  common  conception  of  concussion  of 
the  cord.  The  spinal  cord  is  swung  or  suspended  in  its 
bony  canal,  and  is  separated  from  the  walls  of  that  canal 
on  all  sides  by  a  considerable  interval.  It  is,  indeed,  only 
held  in  position  by  the  nerve  trunks  that  pass  out  from 
it  through  the  intervertebral  foramina,  and  by  its 
connections  with  the  theca.  Above,  it  is  connected 
with  that  part  of  the  brain  that  lies  upon  the  largest 
intracranial  collection  of  the  cerebro-spinal  fluid  (page 
82),  and  it  would  appear  that  the  most  violent  move- 
ments possible  of  the  brain  within  the  skull  could  be 


55°  Surgical  Applied  Anatomy.  [Char.  xxiv. 

but  very  feebly  communicated  to  the  spinal  cord.  The 
cord,  moreover,  within  its  theca,  is  surrounded  on  all 
sides  by  a  space  occupied  by  cerebro-spinal  fluid.  It 
is  diincult  to  understand,  therefore,  how  a  structure 
so  protected  can  be  so  violently  disturbed  by  a  shock 
received  upon  the  body  as  to  undergo  a  grave  and  pro- 
gressive loss  of  function.  The  cord  is,  indeed,  somewhat 
in  the  position  of  a  caterpillar  suspended  by  a  thread 
in  a  phial  of  water.  It  would  probably  be  difficult 
to  permanently  disturb  the  internal  economy  of  such 
an  insect  (even  if  it  had  a  structure  as  elaborate  as  the 
cord)  by  other  than  violence  that  would  be  comparatively 
excessive. 

Contusion  and  crushing:  of  the  cord. — As 
has  already  been  observed,  the  gravity  of  fractures  and 
dislocations  of  the  spine  depends  upon  the  extent  of 
the  damage  received  by  the  cord.  In  these  accidents 
it  is  very  usual  for  some  part  of  the  injured  vertebras 
to  be  projected  into  the  spinal  canal,  so  as  to  press  upon 
or  actually  crush  the  delicate  nerve  centre  that  it  contains. 

It  is  needless  to  observe  that  the  cord  is  extremely 
soft,  and  thus  it  happens  that  it  may  be  entirely  broken 
up  by  violence  without  the  membranes  being  perceptibly 
damaged.  Indeed,  in  fracture-dislocations  it  is  unusual 
for  the  theca  to  be  torn,  and  it  is  possible  for  the  cord 
to  be  quite  crushed  at  some  one  spot  without  the  corre- 
sponding pia  mater  being  in  any  way  lacerated.  The 
amount  of  damage  inflicted  upon  the  cord  will  vary, 
of  course,  with  the  magnitude  of  the  accident ;  but, 
other  things  being  equal,  it  will  be  found  to  be  more 
severely  injured  in  fracture-dislocations  of  the  cervical 
and  dorsal  segments  than  in  like  lesions  in  the  lumbar 
spine.  In  the  atlo-axial  region  the  amount  of  displace- 
ment that  follows  upon  luxation  of  the  two  bones  from 
one  another  is  such  that  the  cord  is,  as  a  rule,  severely 
crushed,  and  death  ensues  instantaneously,  as  is 
seen  in  cases  of  death  by  hanging.  In  the  cervical 
and  upper  dorsal  segments  of  the  column  the  vertebral 
bodies  are  small,  the  spine  is  mobile,  the  fractures  met 
with  in  the  parts  are  usually  due  to  indirect  violence, 


Chap,  xxiv.]  The  Spine.  55  r 

and  arc  associated  with  much  displacement,  hi  the 
lower  dorsal  region,  again,  the  greater  rigidity  of  the 
spine  renders  any  displacement,  when  it  does  occur, 
likely  to  be  considerable.  In  the  lumbar  region,  on 
the  other  hand,  it  must  be  noted  that  the  cord  only 
extends  to  the  lower  border  of  the  first  vertebra.  The 
bodies  of  the  vertebrae,  also,  in  this  district,  are  very 
large  and  cancellous,  and  can  undergo  a  severe  amount 
of  crushing  without  a  corresponding  degree  of  displace- 
ment being  produced.  The  part  is  also  well  protected 
by  the  large  intervertebral  discs,  and  by.  the  immense 
masses  of  muscle  that  surround  the  spine  in  the  loins. 
Such  portion  also  of  the  spinal  cord  as  extends  into 
the  lumbar  region  is  protected  by  the  many  cords  of 
the  cauda  equina,  which,  by  their  looseness  and  com- 
parative toughness,  tend  to  minimise  the  effects  of 
violence. 

The  degree  of  displacement  of  bone  required  to 
produce  pressure  effects  upon  the  cord  is  often  greater 
than  would  be  supposed.  At  post-mortem  examinations 
]  x  irtions  of  injured  vertebrae  have  been  found  encroaching 
upon  the  spinal  canal  to  a  considerable  extent  in  cases 
where  no  evidences  of  damage  to  the  cord  existed  during 
life.  Dr.  J.  W.  Ogle  reports  the  case  of  a  man  who, 
after  an  injury  to  the  neck  from  a  fall,  presented  no 
spinal  symptoms  until  three  days  had  elapsed.  He 
ultimately  became  paralysed,  and  died  thirty-two  days 
after  the  accident.  The  autopsy  revealed  a  dislocation 
forwards  of  the  sixth  cervical  vertebra,  of  such  an  extent 
that  the  body  below  projected  at  least  \  an  inch  into 
the  spinal  canal. 

The  remarkable  manner  in  which  the  cord  will 
accommodate  itself  to  a  slowly  progressing  pressure  is 
often  well  seen  in  the  results  of  chronic  bone  disease 
in  the  column. 

The  symptoms  due  to  injury  to  the  cord  and  to  the 
nerves  contained  in  the  spinal  canal  will  obviously 
depend  upon  the  situation  and  extent  of  the  lesion. 
The  diagnosis  of  the  situation  and  the  lesion  is  compli- 
cated  by  the  relation  the  nerves   bear   to   the  various 


552  Surgical  Applied  Anatomy.  [Chap.  xxiv. 

vertebrae,  and  by  the  fact  that  the  majority  of  the 
great  trunks  arise  from  the  cord  at  a  spot  above  the 
point  at  which  they  issue  from  the  vertebral  canal. 
The  two  highest  nerves,  the  first  and  second  cervical, 
pursue  an  almost  horizontal  course  in  their  passage 
from  the  cord  to  their  points  of  exit  from  the  canal. 
The  remaining  nerves  take  a  more  and  more  oblique 
direction,  until  at  last  the  lowest  nerve  trunks  run 
nearly  vertically  downwards  as  they  pass  to  their 
respective  intervertebral  foramina. 

Points  of  exit. — The  first  cervical  nerve  leaves  the 
canal  above  the  first  cervical  vertebra.  The  remaining 
cervical  trunks  escape  also  above  the  vertebrae  after 
which  they  are  named,  the  eighth  cervical  nerve  leaving 
the  canal  between  the  last  cervical  and  the  first  dorsal 
vertebrae.  The  dorsal,  lumbar,  and  sacral  nerves  have 
their  points  of  exit  below  the  vertebrae  after  which  they 
are  named.  Thus,  the  first  dorsal  nerve  will  pass  through 
the  foramen  between  the  first  and  second  dorsal  verte- 
brae, and  so  on. 

Points  of  Origin  from  the  Cord. 

The  first  cervical  nerve  arises  from  the  cord  opposite  the  interval 

between  the  atlas  and  occiput. 
The  second  and  third  cervical  nerves  arise  from  the  cord  opposite 

the  axis. 
The  fourth,  fifth,  sixth,  seventh,  and  eighth  cervical  nerves  arise 

from  the  cord  opposite  the   third,    fourth,    fifth,   sixth,    and 

seventh  vertebrae  respectively. 
The  first  four  dorsal  nerves  arise  from  the  cord  opposite  the  discs 

helow  the  seventh  cervical  and  the  first,   second,   and  third 

dorsal  vertebra?  respectivel}-. 
The  fifth  and  sixth  dorsal  nerves  arise  from  the  cord  opposite  the 

lower  borders  of  the  fourth  and  fifth  vertebrae. 
The  remaining  six  dorsal  nerves  arise  from  the  cord  opposite  the 

bodies    of    the    sixth,    seventh,    eighth,    ninth,    tenth,    and 

eleventh  vertebrae. 
The  first  three  lumbar  nerves  arise  from  the  cord  opposite  the 

twelfth  dorsal  vertebra. 
The  fourth  lumbar  nerve  arises  from  the  cord  opposite  the  disc 

between  the  twelfth  dorsal  and  first  lumbar  vertebrae. 
The  last  lumbar  nerve,  together  with  the  sacral  and  coccj-geal 

nerves,  arise  from  the  cord  opposite  the  first  lumbar  vertebra. 

It  will  be  seen,  therefore,  that  in  taking  note  of 


chap,  xxiv.]  The  Spine.  553 

the  symptoms  due  to  crushing  the  entire  nerve  con- 
tents of  the  vertebral  canal  at  a  certain  spot,  considera- 
tion must  be  taken,  not  only  of  the  effects  of  damaging 
the  medulla  at  that  point,  but  also  of  the  result  of 
Lacerating  nerve  trunks  that  may  issue  there,  although 
their  origins  arc  above  the  seat  of  lesion.  The  cord  is 
also  very  often  only  damaged  in  part,  or  it  may  entirely 
escape,  while  one  or  more  nerves  are  crushed  by  the 
fractured  vertebrae  or  by  fragments  of  bone  separated 
by  the  lesion. 

In  fracture-dislocations  the  upper  vertebral  body, 
as  already  stated,  usually  glides  forward,  with  the 
result  that  the  anterior  and  antero-lateral  parts  of  the 
cord  are  brought  into  violent  contact  with  the  pro- 
tecting border  of  the  vertebras  below  the  seat  of  lesion. 

It  is  in  these  parts  of  the  cord  that  the  main  motor 
tracts  run,  and  thus  it  happens  that  motion  is  more 
often  lost  in  the  parts  below  the  site  of  the  injury  than 
is  sensation.  If  there  be  partial  motor  and  sensory 
paralysis,  the  disturbance  of  the  former  function  is  likely 
to  be  in  excess  of  that  of  the  latter.  In  no  case,  indeed, 
does  there  appear  to  have  been  a  loss  of  sensation  without, 
at  the  same  time,  some  disturbance  in  the  powers  of 
movement.  If  the  grey  matter  of  the  cord  be  not 
severely  damaged,  reflex  movements  appertaining  to 
that  segment  of  the  cord  can  usually  be  induced  in  the 
paralysed  parts  by  proper  stimulation.  If  those  reflex 
movements  be  lost,  it  may  be  inferred  that  the  grey 
matter  is  broken  up,  and  that  the  entire  spinal  medulla 
has  been  crushed  at  the  seat  of  lesion. 

The  higher  up  the  fracture  in  the  column  the 
greater  is  the  tendency  for  the  function  of  respiration 
to  be  interfered  with.  If  the  lesion  be  at  the  upper  end 
of  the  dorsal  spine,  then  not  only  will  all  the  abdominal 
muscles  be  paralysed,  but  also  all  the  intercostals.  A 
fracture  associated  with  injury  to  the  cord,  when  above 
the  fourth  cervical  vertebra,  is,  as  a  rule,  instantan- 
eously fatal.  The  phrenic  nerve  comes  off  mainly 
from  the  fourth  cervical  nerve,  receiving  contributions 
also  from  the  third  and  fifth.     The  fourth  nerve  issues 


554  Surgical  Applied  Anatomy.  [Chap. xxiv. 

just  above  the  fourth  cervical  vertebra.  If  the  cord 
be  damaged  immediately  below  this  spot,  the  patient 
can  breathe  only  by  means  of  the  diaphragm,  and  if 
the  lesion  be  so  high  as  to  destroy  the  main  contribu- 
tion to  the  phrenic,  respiration  of  any  kind  becomes 
impossible. 

Certain  disturbances  of  the  act  of  micturition  are 
frequent  in  cases  of  injury  to  the  cord.  The  reflex 
centre  for  this  act  is  lodged  in  the  lumbar  enlargement. 
The  irritation  of  the  vesical  walls,  produced  by  the 
increasing  distension  of  the  bladder,  provides  the  needful 
sensory  impulse.  This  impulse  is  reflected  to  the  nerves 
controlling  the  bladder  muscles,  and  especially  to  the 
detrusor  urinse,  and  by  their  contraction  the  organ  is 
emptied  (page  396).  The  action,  however,  can  be  to 
some  extent  inhibited  by  influences  passing  down  from 
the  brain  to  the  lumbar  centre,  and  the  tendency  to  a 
frequent  discharge  of  urine  is  resisted  by  contraction 
of  the  sphincter.  When,  therefore,  any  part  of  the 
cord  is  damaged  that  lies  between  the  lumbar  centre 
and  the  brain,  inhibition  can  have  no  effect.  Imme- 
diately after  the  accident  the  temporary  suspension 
of  reflex  actions  from  shock  produces  some  retention 
of  urine,  and  after  that  the  bladder  empties  itself  at 
frequent  intervals,  the  patient  being  unconscious  of 
the  act  and  unable  to  influence  it. 

If  the  centre  itself  be  damaged  in  the  lumbar  cord, 
the  patient,  after  a  little  retention,  will  suffer  from 
absolute  incontinence  ;  and  a  like  result  will  follow  if 
the  nerve  connections  between  the  cord  and  bladder 
below  the  spinal  centre  have  been  destroyed.  The 
principal  nerves  connecting  the  medulla  spinalis  with 
the  bladder  are  the  third  and  fourth  sacral. 

The  act  of  defaecatioh  also  is  apt  to  be  disturbed 
in  a  like  manner.  Here  there  is,  as  in  the  previous 
case,  a  reflex  centre  in  the  lumbar  enlargement,  with 
motor  and  sensory  nerves  connecting  it  below  with 
the  rectum  and  its  muscles  ;  and  also  between  this 
centre  and  the  brain  are  tracts,  but  little  known,  along 
which  inhibitory  actions  can  extend. 


chap,  x x  i  v.  ]  The  Spine.  555 

When  the  centre  itself  is  damaged,  or  the  connection 
severed  that  unites  it  with  the  viscus,  the  patient  will 
suffer  from  incontinence  of  fa?ces  and  will  be  unable  in 
any  way  to  control  the  act.  When  the  cord  is  damaged 
at  any  spot  between  the  centre  and  the  brain,  then  the 
act  of  defaecation  will  be  performed  at  regular  intervals, 
without  either  the  patient  being  conscious  of  the  act 
or  being  capable  of  inhibiting  it. 

In  some  injuries  to  the  cervical  cord  the  patient 
has  suffered  from  severe  vomiting  for  some  time  after 
the  accident,  or  has  exhibited  a  remarkable  alteration 
in  the  action  of  his  heart.  Mr.  Erichsen,  for  example, 
reports  the  case  of  a  man  who,  after  a  severe  blow  upon 
the  cervical  spine,  continued  to  vomit  daily  for  several 
months.  In  the  other  category,  instances  have  been 
recorded  when  the  pulse  has  sunk  as  low  as  48,  or  even 
as  36,  and  20,  after  lesions  to  the  column  in  the  neck. 

These  changes  are  supposed  to  be  due  to  disturbance 
of  the  vagus,  and  it  is  further  suggested  that  the  morbid 
influence  is  conveyed  to  the  vagus  by  the  spinal  accessory 
nerve  with  which  it  is  so  freely  associated. 

It  should  be  remembered  that  the  spinal  accessory 
trunk  has  origin  from  the  cord  as  low  down  as  the  sixth 
or  seventh  cervical  nerves.  Some  details  concerning 
the  position  of  centres  in  the  spinal  cord,  connected  with 
areas  of  skin,  groups  of  muscles  and  viscera,  have  been 
given  already  when  dealing  with  the  nerve  supplies 
of  the  extremities  and  abdomen  (see  pages  533  and  368). 

Operations  upon  the  cord.  —  Mr.  Victor 
Horsley  and  others  have  cut  down  upon  the  spine  and 
removed  a  tumour  from  the  spinal  cord  with  perfect 
success,  and  with  relief  to  the  symptoms  from  which 
the  patient  was  suffering.  The  spinal  canal  has  also 
been  exposed  in  certain  cases  where  callus  in  an  old 
fracture  of  the  spine  was  pressing  upon  the  cord,  or  where 
a  small  osseous  growth  was  encroaching  on  the  canal. 


INDEX. 


Abdomen,  blood  vessels  of,  284,  292, 

370 
,,  blows  on  the,  387 

,,         congenital      deformities 

of  the,  29S 
,,  fascia  of,  286,  311 

,,         lymphatics  of  the,  292 
,,         nerves  of,  293,  368 
,,         parietes  of,  282,  2S5,  2S6, 

291,  311 
,,         skin  of  the,  285 
,,         surface  anatomy  of  the, 

282 
,,  wounds  of  the,  292 

"  Abdominal  belt,"  286 

,,  ,,        connective  tis- 

sue and  abs- 
cesses, 291 
Abdominal  viscera,   nerve    supply 
Abscess,  alveolar,  1  It  J  [of,  368 

,,         axillary,  204 
,,        cervical,  143,  144 
,,         gluteal,  426 
,,        hepatic,  352 
„        iliac,  312 
,,        in  antrum,  95 
,,  mastoid  cells,  76 

,,  testis,  409 

,,  the  abdominal  parietes, 

292,  315 
,,  the  scalp,  6 

,,  the  temporal  fossa,  S 

,,        intercostal,  174 
,,        ischio-rectal,  384 
,,        lumbar,  312,  315 
,,       mammary,  177 
,,        mediastinal,  144,  184 
,,        orbital,  44 
,,        palmar,  263 
,,        parotid,  103 

pelvic,  381,  43S 
,,        perinephric,  362 
,,        perityphlitis  338 
,,        plantar,  505 
,,        popliteal,  470 
,,        post- pharyngeal,  131 
,,        prostatic,  398 


Abscess,  psoas,  313,  43 1 
,,        renal,  363 
,,        retro-peritoneal,  313 
,,         thecal,  265 
Acetabulum,  438 

,,  fractures  of,  375 

Aeromio-clavicular  joint,  197 

,,  ,,      disloca- 

tions of,  199 
Acromio-thoracic  artery,  190 
Acromion  process,  fracture  of,  200 
Addison's  disease,  369 
Adductor  longus  muscle,  431,  435 
Air  in  veins,  163,  207 
"  Alderman's  nerve,"  73 
Alexis  St.  Martin's  case,  330 
Alveolar  abscess,  116 
Amputation  (see    Ann,    Leg,    etc.. 

amputation  of,  etc.) 
Anal  triangle,  383 
Anastomotica  magna,  468 
Aneurism,  aortic,  160,  370 
,,  axillary,  207 

,,  in  the  neck,  160,  162 

,,         of  the  posterior    tibial 

artery,  493 
,,  popliteal,  472 

Ankle,  500,  510 

,,      fascia;  of,  504 
,,      joint,  500,  510 
,,         ,,      amputation  at,  528 
,,         ,,      disease  of,  511 
,,  ,,      dislocations  at,  512 

,,         ,,     fractures  about,  512 
,,       surface  anatomy  of,  500 
,,      tendons  of,  504,  507 
Annular  ligaments  of  ankle,  506 
fingers,  263 
,,  ,,  wrist,  263, 266 

Anterior  crural  nerve,  436,  445,  533 
Antrum  of  Higlnnore,  93 

,,  mastoid,  76 

Anus,  385,  419 

,,      imperforate,  344 
Aorta,  abdominal,  284,  870 

,,      thoracic.  160,  182 
Aortic  orifice,  182 


558 


Surgical  Applied  Anatomy. 


Aponeuroses  (see  Fascia?) 
Appendicitis,  336  1 
Appendix  vermiformis,  336,  33S 
Aqueous  humour,  59 
Arachnoid,  30,  547 
Arcus  senilis,  49    ' 
Arm,  223 
,,     amputation  of,  220 
,,     fascia  of,  224 
,,     nerves  of,  275 
,,     skin  of,  224 
„     surface  anatomy  of,  223 
Arnold's  nerve,  72 
Arteries    (see    Axillary,    etc.,    and 

Blood-vessels) 
Arteriotomy,  12 
Arterio-venous  aneurisms,  45,  234. 

435 
Astragalus,  dislocations  of,  51S 

,,  fractures  of,  525 

Atlas,  131 

Atlo-axial  portion  of  spine,  540 
Auditory  meatus,  external,  69 

,,  ,,        its  relations,  71 

Auricle  (see  Ear) 
Auricles,  supernumerary,  68 
Auriculo-ventricular  orifices.  1S2 
Axilla,  1S8,  202 

,,      suspensory  ligament  of,  204 
Axillary  abscess,  204 

.,        artery,  187,  1SS,  207 
,,        fascia?,  203 
,,        glands,  177.  205 
„        nerves,  20S 
.,        vein,  206 
Axis,  131 
Azygos  veins,  184 

Barbadoes  leg,  437 

Base  of  skull,  fractures  of.  25 

Basilic  vein,  233 

Bend  of  elbow,  230 

Bent  arm  after  venesection,  235 

Biceps  tendon  in  arm,  212 

,,  ,,  ham,  471 

Bile  duct,  rupture  of  the,  355 
,,        ,,     relationships  of,  254 
Bladder,  391,  420 

,,        distension  of,  391 

„        double,  397 

„        extroversion  of,  293 

,,        fasciculated,  396 

,,        female,  397 

,,        foreign  bodies  in,  397 

,,        found  in  hernia?,  393 

,,        male,  391 

.,        mucous  membrane  of  the. 
395 
nerves  of,  396 


Bladder,  of  child,  398 

.,        puncture  of,  above  pubes, 

393 
,,  ,,  per  rectum,  394 

.,      relations  to  the  peritoneum, 

393 
,,        rupture  of  the,  394 
,,        sacculated,  396 
,,        stabbed  through  buttock, 

430 
,,        stone  in  the,  387 
Blood-vessels  of  abdomen,  284,  292, 
370 
.,  abdominal    walls. 

292 
.,  auditor}'     meatus. 

,,  brain,  38 

,,  breast,  17S 

,,  buttock,  425,  428 

foot,  502,  50S 
globe,  52 
.,  hand,  25S,  266 

,,  heel,  529 

,,  knee,  471 

leg,  492 
,,  naves,  90 

,,  neck,  137,  100 

,,  orbit,  45 

.,  palate,  127 

pelvis,  3S2 
,,  perineum,  336 

.,  pinna,  72 

.,  rectum,  417 

,,  retina,  54 

,,  scalp,  12 

,,  Scarpa's    triangle. 

432,  435 
,,  spermatic  cord,  410 

,,  tympanum,  80 

Brachial  artery,  223,  231,  235 

,,  .,        abnormalities    of, 

226 
,,  ,,        in      phlebotomy, 

234 
,,  ,,        ligature  of,  226 

,,        fascia,  224 
,,        plexus,  139,  14S,  178,  278 
Brachialis  anticus,  225 
Brain,  32,  38 

,,      and  skull  relations,  32 
,,      basal  ganglia  of,  37 
,,      blood-vessels  of  the,  3S 
,,      concussion  of  the,  38 
,,      convolutions  of,  35 
,,      cortex  of,  37 
,,      fissures  of,  35 
,,      injuries  t  >,  32 
,,      membranes  of,  2S 


Index. 


559 


Brain,  motor  centres  of,  '■', 
sulci  i 
.,      surface  relationships  of,  32 

„      wounds  of,  4u 
Branchial  fistula?,  68,  166 

Brasdor's  operation,  101 
Breast  (see  Mamma),  170 

,,     abscess  of,  177 
Bregma,  15 
Bronchi,  162,  154 

,,         foreign  bodies  in,  154 
Bronchial  lymphatic  glands,  184 
Bronchocele,  255 
Brunner's  glands  in  burns,  333 
Bryant's  method    of  dividing  the 
muscles  of  the  palate, 
129 
,,         triangle,  424 
Buccal  cavity,  118 

,,  ,,      in  embryo.  1-27 

,,       nerve,  101 
Bunions,  ">07 

Bursa:  about  the  elbow,  236 
,,  ,,        four.  506 

.,  ,,         hum.  473 

shoulder,  209,  211 
over   the  great  trochanter. 
4ii7 
,,  „  ischial         tuber- 

osity. 427 
,,  ,,         knee-joint,     469, 

47a 
,,      patellar,  469 
.,      subacromial,  l'1  1 
Buttocks,  423 

.,         arteries   and    nerves    sf 
the,  425,  428 
fascia  of,  426 
„  fold  of,  424 

,,         surface  anatomy  of,  423 

Caecum,  336,  348 

,,      foreign  bodies  in.  337 

,,      hernia  of,  337 

,,      in   intestinal   obstruction, 
339 

,,      opening  of, 

,,       position  of,  33(5 
Caesarian  section,  375 
Calcaneo-astragaloid  joint,  518 

,,       -cuboid  articulation,  520 

„      -scaphoid  ligament,  524 
Canal  of  Xuck,  hernia  in,  300 
Cancrum  oris.  96 
Capsule  of  Tenon,  42 
Cardiac  orifice  of  stomach,  321 
Carotid   artery,    70,    132.    133,    137, 
144,  101,  1S3 
,,  ,,  aneurism  of,  101 


Carotid   artery,  destroyed   by  abs- 
cess, 144 
,,  ,,         ligature  of,  I'd 

,,  ,,  wounds  of,  140 

,,        tubercle,  130,  102 
Castration,  411 
Cataract,  58 
Catheterism  of  Eustachian  tube,  80 

,,  of  urethra,  401 

Centre  of  gravity  of  an  adult  body, 

372 
Cephallueinatomata,  7 
Cephalic  vein,  1S7,  230,  233 
Cerebral  circulation,  38 

,,        localisation,  37 
Cerebrospinal  fluid,  27,  547. 
Cervical  (see  Xeck) 

.,        sympathetic,  paralysis  of, 
47 
Cervico-dorsal  part  of  spine,  540 
Charbon,  97 
Cheek,  96 

Cholecystectomy,  355 
Cholecystenterostomy .  :; •".  5 
Cholecystotomy,  355 
Choparfs  operation,  530 
Chorda  tympani,  SI 
Choroid,  50 
Ciliary  zone,  56 
Circumcision,  405 
Circumcorneal  zone,  56 
Circumflex   artery,    external,    rap- 
ture of,  -At*. l 
,,  .,       internal,  wound 

of,  401 
,)  :,       posterior,     189, 

200 
,,  nerve,  ISO,  200 

Cirsoid  aneurism,  1:: 
Clavicle,  185,  ISO,  190 

,,         dislocations  of,  107,  199 
,,         excision  of,  101 
,,         fractures  of,  101 
„         movements  of,  19S 
„         ossification  of,  194 
,,  relations  of,  100,  194 

Clelt  palate,  120 
Clergyman's  sore-throat,  150 
Club-foot,  520 
Coccygeus,  37S,  379 
Coccygodynia,  370 
Cochin  leg, 437 
Coeliac  axis,  2S4,  370 
Colectomy,  348 
Colles'  fascia,  385 

,,     fracture,  200,  270 
Coloboma  iridis,  52 
Colon,  340 

,,      ascending,  341 


$6o 


Surgical  Applied  An  atom  V. 


Colon,  descending,  341 

,,      malformation  of,  343,  345 
,,       operations  on,  345 
,,      stricture  of,  340 
transverse,  340,  341 
Colotomy,  iliac,  347 

,,  lumbar,  345 

Compression  of  brain,  29 

,,  cord,  550,  553 

Concussion  of  brain,  38 
,,  cord,  549 

Congenital  club-foot,  520 
,,  exomphalos,  29S 

,,  fistula?,  68,  166 

.,  hernia,  302,  304,  305 

,,  hydrocele,  303 

„  malformations  of  anus 

and  rectum,  420 
.,  malformations  of   blad- 

der, 29S 
,,  malformations  of  colon, 

343,  345 
.,  malformations  of  penis, 

406 
,,  tumour  of   sterno-mas- 

toid,  140 
Conjunctiva,  64 
Contre-coup,  fracture  by,  25 
Convolutions  of  brain,  motor  cen- 
tres on,  37 
,,  of  brain,  relations  of, 

32 
,,  of  brain,  relations  of, 

to  skull,  32 
Coraco-acromial  arch,  210 
Coracoid  process,  187 

,,  fracture  of,  201 

Cord,  spinal,  545 

,,  concussion  of,  549 

,,  contusion  of,  550 

,,  injuries  to  the,  symp- 

toms of,  551 
Cornea,  48 
Coronal  suture,  15 
Coronoid  process,  244 
Corpus  striatum,  37 
Coryza,  85 
Coup  de  fouet,  492 
Cowper's  duct,  412 
Craniectomy,  28 
Cranio-tabes,  16 
Cranium,  bony  vault  of,  15 
Cremaster  muscle,  410 
Cremasteric  artery,  410 
Cretinism,  157 
Cribriform  plate,  84 
Cricoid  cartilage,  148,  149 
Crico-thyroid  space,  136,  154 
Crutch  paralysis,  227 


Cuboid  bone,  500 
Cuneiform  bone,  inner,  500 

,,  ,,      dislocation 

of the, 526 
,,  ,,      fracture    of 

the,  526 
Curves  of   the   vertebral    column, 

537 
Cut  throat,  146 
Cyphosis,  538 

Dartos,  386,  407 
Deltoid  muscle,  20S 
,,      region,  1S7,  20S 
,,      tubercle,  1S5 
Descending  palatine  artery,  127 
Diploic  veins,  13 
Dislocation  (see  the  several  bones 

and  joints) 
Dorsal  vein  of  penis,  386 
Dorsalis  pedis  artery,  50S 

,,        scapula?  artery,  1S9 
Dorso-lumbar  part  of  spine,  540 
Drop-wrist,  278 
Duodenal  fossa,  332 
Duodenum,  332 

,,  suspensory  muscle  of, 

332 
Dupuytren's  contraction,  261 

,,  fracture,  515 

Dura  mater,  2S,  546 

,,  fungus  of,  30 

Dysphonia  clericorum,  150 

Ear,  6S 

,,    bleeding  from,  in  fractures  of 
base  of  skull,  26 

,,    blood  supply  of,  72 

,,    coughing,  73 

,,    external,  68 

, ,    frost  bite  of,  72 

,,    gangrene  of,  72 

,,    haematomata  of,  72 

,,    nerves  of,  72 

,,    polypi  of,  71 

,,    sneezing,  73 

,,    tophi  in,  69 

,,    watery  discharge  from,  27 

,,    yawning,  73 
Elbow,  230,  232 

,,      burs*  about,  236 

,,      dislocations  of  the,  238 

„      fold  of  the,  230 

,,      fractures  about,  241 

,,      gland  of,  235 

„      joint,  236 

,,  „     disease  of,  237 

,,  ,,      sprains  of,  237,  241 

,,      resection  of  the,  245|    (JYy 


Index. 


56i 


Elbow,  surface  anatomy  of  the,  230 

,,      veins  about,  233 
Elephantiasis  arabnm,  437 
Emissary  veins  of  skull,  13 
Emphysema,  179 
Bncephalocele,  IT 
Encysted  hydrocele   of  the  cord, 

304 
Enterectomy,  335 
Enteroraphy,  335 
Enterotomy,  335 
Epididymis,  409 

Epiphysis,  lower,  of  femur  in   ex- 
cision of  knee, 
48S 
,,  ,,       in    knock-knee, 

481 
„  of  acromion,  separation 

of,  200 
,,  of  clavicle,    separation 

of,  194 
,,  of  coracoid  process,  201 

,,  of  femur,  separation  of, 

444,  449,  485 

,,         of  humerus,  separation 

of,  220,  243 

of  olecranon,  244 

,,         of  pelvis,  separation  of, 

374 
,,  of  radius,  separation  of, 

244,  272 
,,  of  tibia,  separation  of, 

48S,  498 
,,         of     third     phalanx    in 
whitlow,  266 
of  upper  limb,  2S1 
Epipteric  bone,  19 
Epispadias,  406 
Epistaxis,  90 

Estlander's  operation,  174 
Eustachian  catheter,  to  pass,  80 

,,         tube,  78 
Excision  (.see  special  parts) 
External  auditory  meatus,  OS 

,,        auditory    meatus,    blood 

supply  of,  72 
,,        auditory     meatus,    nerve 

supply  of,  72 
„        carotid,    bleeding    from, 
163 
Extravasation  of  urine,  2S6,  380 
Eye-ball,  48 

,,        blood  supply  of  the,  52 
,,         dangerous  area  of,  50 
,,       nerves  of  tin  .  5 1 
Eyelids,  62 

Face,  95 
,,     development  of,  99 

-K 


Face,  injuries  to,  97 
,,      nerves  of,  99 
,,      vessels  of,  97 
Facial  artery,  27 

,,     nerve,  98,  106 
Fascia,  abdominal,  311,  386 
,,       axillary,  203 
bicipital,  234 
,,       cervical,  141 
,,       clavi-pectoral,  204 
,,       iliac,  311 
,,       lata,  426,  433,  459 
,,       lumborum,  315 
,,       obturator,  379 
,,       of  arm,  224 
,,       of  buttock,  420 
,,       ofColles,  3S5 
,,       of  deltoid  region,  208 
,,       of  foot,  504 
,,       of  leg,  491 
,,       of  palm,  20,  261 
,,       of  scalp,  1,  6 
,,       of  Scarpa's  triangle,  433 
„       of  thigh,  426,  433,  459 
,,       orbital,  42 
,,       palmar,  261 
parotid,  103 
pectoral,  203 
pelvic,  379 
.,       perineal,  3S5 
,,       popliteal,  470 
,,       prevertebral,  143 
,,       recto- vesical,  3S0 
temporal,  7 
transversalis,  311 
Fasciculated  bladder,  396 
Femoral  hernia,  306 

.,       vessels,  432,  435,  4(il 
Femur,  dislocations  of,  44'.' 

,,       fractures  of,  440,  401 
Fenestra  ovalis,  76 

,,       rotunda,  76 
Ferguson's  method  of  dividing  the 

muscles  of  the  palate,  128 
Fibula,  497 

,,       fractures  of,  495,  497,  512 
Filth  nerve,  101 

,,      section  of,  101 
Finger  "snap,''  264 

,,      little,  congenital  contraction 

of,  264 
,,      "mallet,"  270 
Fissure,  of  Rolando,  35 
Sylvius,  35 
Fissures  of  brain,  relations  of,  35 

parietal,  19 
Fistula    ai   the  navel,  289 

,,       between   the  gall  bladdei 
and  gut,  342 


562 


Surgical  Applied  Anatomy. 


Fistula,  congenital,  6S,  166 
,,        gastric,  324 
,,        in  ano,  385 
,,        lachrymal,  67 
,,        salivary,  10S 
.,       vesico- vaginal,  413 
Flat-foot,  522 
Fold,  gluteal,  424 
Fontanelle,.  sagittal,  19 

,,  temporary  occipital,  18 

Fontanelles,  15 
Foot,  abscess  of,  505 
,,      amputations  of,  528 
,,      arches  of,  517 
,,      blood-vessels  of,  502,  508 
,,      chief  .joints  of,  517 
,,      dislocations  of,  518,  527 
,,      fasciae  of,  504 
,,      fractures  of,  525 
,,      integuments  of,  502 
„      lymphatics  of,  510 
,,      nerves  of,  504 
,,      surface  anatomy  of,  500 
,,      synovial  membranes  of,  527 
,,     the,  500,  504,  517 
Foramen  caecum  of  tongue,  124 
,,        of  Majendie,  32 
,,  Monro,  33 

Fore-arm,  246 

,,         amputation  of  the,  252 
,,         bones  of  the,  248 
,,         fractures  of  the,  250 
,,         luxations  of  the,  238 
,,         surface  anatomy  of  the. 

246 
,,         vessels  of  the,  247 
Fossa  duodeno-jejunalis,  333 
,,      ischio-rectal,  3S2,  384 
,,      nasal,  84 
,,      of  Rosenmuller,  SO 
,,      subclavicular,  187 
Fracture  (see  the  several  bones) 
,,        dislocation     of    the    ver- 
tebral column,  540 
,,        helicoide,  462,  496 
Frsenum  linguae,  120 
Frontal  sinus,  92 

,,         ,,      infundibulum  of,  93 
Fungus  of  the  dura  mater,  30 
,,  testicle,  409 


Gall  bladder,  354 

,,        fundus  of,  350 


nerve  supply  of,  855 
operations  on,  355 
rupture  of  the,  355 
obstructed    by   mov- 
able kidney,  364 


Gall  stones,  342,  354 
Gangrene  of  nose,  82 
,,  pinna,  72 

,,  the  leg  and  embolism. 

493 
Gasserian  ganglion  affected  by  abs- 
cess spreading 
from    parotid, 
105 
,,  ,,  removal  of,  102 

Gastrectomy,  327 
Gastrocnemius  muscle,  490 

,,  ,,         rupture    of 

the,  492 
Gastroenterostomy,  328 
Gastrostomy,  326 
Gastrotomy,  326 
Generative  organs,  female,  412 

,,  ,,        male,  405 

Genito-crural  nerve,  410,  436 
Genu- valgum,  480 
Gladiolus,  171 
Glaus  penis,  405        (J 
Glaucoma,  50,  60 
Glottis,  149 
Gluteal  abscess,  426 
,,      aneurisms,  428 
,,      artery,  425,  42S 
,,      bursa?,  427 
,,      fascia,  426 
„      fold,  424 
,,      region,  423 
Gluteus  maximus,  427 

,,  ,,         rupture  of,  427 

Goitre,  155 

Great  occipital  nerve/162 
Groin,  region  of,  430 
Gullet  (see  CKsophagus) 
Gums,  120 

Gustatory  nerve,   Moore's  method 
of  dividing  the,  119 


Hyematomata  of  scalp,  7 

,,  on  septum  nasi,  90  A 

,,  the  pinna,  72 

Haemoptysis,  180 

Haemorrhage  from  choroid,  50 

,,  ,,    frsenum    lingua?, 

121 
,,  ,,    intercostal    ves- 

sels, 174 
,,  s,    tongue,  121 

,,  ,,    tonsil,  134 

,,  in  lithotomy,  3S2,  388 

,,  into  vitreous,  54 

,,  in  tracheotomy,  153 

,,  meningeal,  29 


Index. 


5^3 


Haemorrhoids]  vessels  and  nerves, 

417 

Hemothorax,  180 
Hallux  rigidus,  527 

,,       valgus.  527 
Hamstring  muscles,  460,  470 

Hand,  250,  258 

,,      amputation  of,  274 
~      blood-vessels    and    lympha- 
tics of,  258,  266 

dislocations  of,  27-2.  273 
fasciae  of,  260,  201 
,,      surface  anatomy  of.  2 
,,      synovial  sheaths  of,  264 
Hanging,  mode  of  death  from,  550 
Hard  palate.  127 
Hare-liy,  126 
Heart,  182 

,,      its  relation  to  the  surface. 

182 
,,      valves  of,  182 
,,      wounds  of,  183 
Heel,  blood-vessels  of,  529 
integuments  of,  529 
Helicoidal    fractures    of    Leriche, 

462,  40S 
Hernia,  congenital,  299,  304,  305 
,,       diaphragmatic,  310 
,,       direct,  300 
,,       encysted,  304 
,,        femoral,  306 
,,        infantile,  304 
,,        inguinal,  299,  305 
,,        into  the  funicular  process. 

305 
,,       ischio-rectal,  310 
lumbar,  310 
mesenteric,  333 
obturator, 
omental,  318 
perineal,  210 
pudendal,  310 
,,       rare  forms  of,  310 

retro-peritoneal,  334 
,,       sciatic,  310 

umbilical,  2SS,  310 
,,        vaginal,  413 
Herniotomy,  306,  309 
Hip,  dislocations  of,  449 
,,    joint,  43S 

,,        ,,      amputation  at  the.  456 
,,        ,,      congenital    dislocations 

of,  450 
„        ,,      disease,  439,  444 

,,      fractures  about,  446 
,,      movements  of,  439 
,.      region  of  the,  423 
Hippocratic  hand,  260 
Holden's  line,  I'd 


Hottentot  Venus,  425 

Human  tails,  37S 

Humerus,  dislocations  of,  214 

iractures  of,  219,  227,  241 
,,  non  -  union 

after,  22S 
Hydatid  cyst  in  the  liver,  354 
Hvdrencephalocele.  17 
Hydrocele,  303,  408 

,,         of  the  neck,  167 
Hydrocephalus,  16,  32 
Hyoid  bone,  136,  148 

,,  ,,    accessor^' glands  about. 

156 
,,         ,,    fracture  of,  14  S 
Hypertrophy  of  the  prostate,  399 
Hypoglossal  nerve,  162 
Hypopyon,  60 
Hypospadias,  406 
Hypothenar  eminence,  255 
Hysterical  hip,  445 
,,         knee,  445' 

Ichthyosis  linguae,  121 
Ileo-cajcal  intussusception,  339 
,,         region,  336 
,,         valve,  339 
Ileo-colic  intussusception,  339 
Ileum  (see  Intestine,  small) 
Iliac  abscess,  312 
,,     colotomy,  347 
,,    fascia,  311 
Ilio-psoas  muscle,  312,  434 
Ilio-tibial  band,  426,  459,  466 
Indirect  hernia,  300 
Inequality  of  limbs  in  length,  464 
Infantile  hernia,  304 
Inferior  dental  nerve,  dividing  the, 
101 
,,        maxilla,  deformities  of,  115 
,,  ,,        dislocations  of.  112 

,,        excision  of,  113 
. ,        fracture  of.  Ill 
,,        subluxation  of  the. 
113 
thyroid  veins,  136,  146 
Infraorbital  foramen,  100 
,,         artery,  100 
,,  nerve,  100 

Inguinal  caiial,  299,  305 
,,        colotomy.  347 
„        hernia,  2*99,  305 
Innominate  artery,  154, 161, 162,  1S2 

,,  bone,  372 

Intercostal  artery,  174 
,,  spaces,  173 

Intercosto-humeral  nerve,  177 
Internal  mammary  artery.  175 
Interparietal  bone,  19 


564 


Surgical  Applied  Anatomy. 


Inter-scapulo-thoracic  amputation, 
202 

Intersigmoid  fossa,  343 

Intervertebral  discs,  537 

Intestine,  foreign  bodies  in,  338 
large,  340 
,,  ,,     operations  on,  345, 

,,  ,,     stricture  of,  340 

,,         resection  of,  34S 
,,         small,  328 
.,  .,      diverticula  of,  331 

,,  „      injury  of,  329,  330 

„  ,,      length  of,  328 

„  ,,       operations  on,  33-3 

,,  ,,       position  of,  329 

Intestinal  anastomoses,  348 

Intussusception,  339 

Inversion  of  the  testicle,  409 

Iridectomy,  52 

Iris,  50 

Iritis,  51 

Ischio-rectal  abscess,  384 
„  fossa,  3S2,  384 

,,  hernia,  310 

Isthmus  of  the  thyroid,  153 

,,  ,,        division  of. 

153,  150 ' 

Jacob's  ulcer  of  the  eyelid,  63 
Jaws    (see    Inferior    and    Superior 

maxilla) 
Jejunum  (see  Intestine,  small) 
Joints,    surgical    classification     of 

the,  210 
Jugular  vein,  76,  132,  134,  138,  140 

Keloid,  its  frequent  seat.  170 
Kidney,  360 

,,       abnormalities  of,  364 
,,       abscess  of,  362 
.,       hilum  of,  300 
,,       horse-shoe,  3»>4 
,,       its  relations,  300 
,,       movable,  303 
,,       nerve  supply  of,  364 
,,       operations  on,  366 
,,       pelvis  of,  308 
,,       rupture  of,  302 
,,       vessels,  point  of  origin  of, 
285 
Knee,  blood  supply  of  the,  471 
,      burste  about,  409,  473 
,,      dislocations  of  the,  485 
,,      fractures  about,  485 
,,      integuments  of,  469 
,,      joint,  474 
,,  ,,      amputation     through, 

489 
,,  ,,      disease  of,  477 


Knee  joint,  excision  of  the,  487 

,,      region  of,  465 

,,       surface  anatomy  of  the,  405 
Knock-knee,  480 
Kraske's  operation,  418 


Labia  majora,  412 
Labyrinth  of  ear,  81 

Lachrymal  abscess,  00 
,,         apparatus,  65 
,,         gland,  05 
,,         sac,  00 
Lacuna  magna,  urethral,  404 
Lambda,  15 
Lambdoid  suture,  15 
Lamina  cribrosa,  50,  02 
,,      fusca,  50 
,,      suprachoroidea,  50 
Laminectomy,  455 
Laryngeal  glands,  105 
Laryngotomy,  151, 154 
Larynx,  136,  148 

,,        excision  of,  150 
,,        foreign  bodies  in,  154 
,,        fracture  of,  149 
,,        lymphatics  of,  151 
,,        mucous  membrane  of,  149 
Lateral  lithotomy,  387 
Leg,  489 
,,    amputation  of,  499 
.,    fasciae  of,  491 
,,    fractures  of,  495 
.,    rickets  affecting  bones  of,  499 
,,    skin  of,  491 
,,    surface  anatomy  of,  489 
,,    vessels  of,  492 
Lens,  57 

.,      artery  to  the,  00 
Levator  ani,  379,  384 

,,  ,,    relation    to   fistula    in 

ano,  385 
,,        palati.  128 
,,        palpebral,  03 
Ligamentum  patellae,  405,  470,  4S3 
,,  pectinatuin  iridis.  59 

Ligament,  pterygo-maxillary,  119 
Lighterman  s  bottom,  427 
Linea  alba,  283,  287 

,,      semilunaris,  283 
Lingual  artery,  121 
,,        tonsil.  123 
Lipomata  in  deltoid  region.  209 
,,        in  neck,  139 
,,         in  Scarpa's  triangle,  133 
,,         on  the  buttock,  125 
,,         rare  on  face,  90 
Lips,  117 


Index. 


-:'y. 


Lisfranc's  amputation,  530 
Litholapaxy,  3S7 
Lithotomy,  lateral,  3S7 

.,  ,,      in  children.  389 

„  ,,      parts      divided 

in,  38S 
,,  median,  3S9 

,,  ,,       versus  lateral, 

3S9 
,,  suprapubic,  390 

Little's  operation,  343J  . 
Liver,  34$ 

,,     abscesses  of,  352 
,,      fixation  of,  350 
,,      operations  on,  352 
,,     in  pyaemia,  352 
,,      protrusion  of,  352 
,,      ptosis  of,  350 
,,      relations  of,  34S 
.,      Riedel's  lobe,  350 
,,      ruptures  of,  351 
,,      wounds  of,  351 
Lockjaw,  115 

Lordosis  in  hip  disease.  441 
Lower  limb,  length  of,  4<:>4 

,,  lymphatics  of,  43i> 

,,  nerve  supply  of,  533 

Luksemic     enlargement     of     the 

spleen,  353 
Lumbar  colectomy,  348 
,,      colotomy,  345 
,,      fascia,  315 
,,      glands,  370 
,,      hernia,  310 
,,      puncture,  548 
,,      region,  314 
,,      spine,  538 

,,  ,,      injuries  to,  539,  546, 

548,  553,  554 
Lung  17S 
,,      and  secondary  deposits,  ISO 
,,      cavities,  drainage  of,  181 
,,      hernia  of,  14S,  ISO 
,,       in  neck,  148,  178 
,,      relations  of  to  surface,  17S 
,,      rupture  of,  ISO 
,,       wounds  of,  179,  180 
Luschka's  tonsil,  SO,  131 
Lymphangioma  cavernosum,  124 
Lymphatic  glands  and  vessels  (-•• 
each  region) 


Klacro-glossia,  193 

Malar  bone,  103 

,,        ,,      fracture  of.  1"3 
Malleoli,  .300 

,,        fractures  of.    in    disloca- 
tions of  the  foot,  513 


Mamma,  175 

,,        arteries  of,  17^ 
,,        cancer  of,  170 
,,        capsule  of,  176 
,,        development  of,  170 
,,        in  groin,  433 
,,        lymphatics  of.  176 
,,        nerves  of,  177 
Mammary  abscess,  177 
Manubrium,  171 
Mastication,  muscles  of,  1 15 
Mastoid  antrum.  76 
,,      cells,  78 

,,  ,,      perforation  of,  7S 

Maxillae  (see  Inferior  and  Superior) 
Meatus,  the  auditory,  6S 
Meatusesjof  nose,  S7 
Meckel's  diverticulum,  290,  331 

,,        ganglion,  100 
Median  lithotomy,  3S9 

nerve,  220,  247,  280,  429 
Mediastina,  1S4 

,,         abscess  of,  144,  184 
Medio-tarsal  joint,  501,  520 

,,  amputation  at,  530 

Meibomian  glands,  63 
Melanotic  growths  of  choroid.  51 
Membrana  tympani,  74 
Membranous  urethra,  403 
Meningeal  artery,  9,  29 

,,        haemorrhage,  29 
Meninges  of  brain,  2S 

,,  spinal  cord,  546 

Meningitis  from  abscess  in  the  ear, 
71,  75,  77,  86 
,,         (spinal)  from  bed-sores, 
547 
Meningocele,  17,  S3,  86 
Mesenteric  arteries,  2S4,  370 
,,       hernia,  333 
,,       holes,  320 
Mesentery,  31S 

,,  length  of,  319 

,,  prolapse  of,  320 

Meso-colic  hernia,  334 

,,    -colon,  341 
Metacarpo  -  phalangeal     joint     of 

thumb,  dislocations  at,  273 
Metatarsal  bone  of  great  toe,  am- 
putation of,  531 
,,         bones,  fractures  of  the, 
526 
Metatarsophalangeal  articulations, 
501 
,,  ,,        joint  of  great 

toe,  dislocation  at.  326 
Middle  meningeal  artery.  29 
Miner's  elbow.  286 
Motor  centres  on  the  cortex,  37 


566 


Surgical  Applied  Anatomy. 


Motor  paralysis  in  injuries  to  cord, 

553 
'  Month,  118 

Mucous  polyp  of  nose,  89 
Mumps,  105 
Muscse  volitantes,  60 
Musculo-spiral  nerve,  227,  278 
Myxcedema,  157 

Nail,  260 

Nares,  anterior,  84 

,,      posterior,  S4 
Nasal  bones,  S3 

,,  ,,      fracture  of,  83 

,,       cavity,  84 

,,      cavities,  lymphatics  of,  92 

,,  ,,         blood-vessels  of,  90 

,,  ,,         nerve  supply  of,  91 

,,      douche,  85 

j,      duct,  67 

,,      fossa?,  84 

,,      mucous  membrane,  SS 

„      polypus,  89 
Neck,  135 

,,       abscess  of,  143,  144 

,,       fasciae  of,  141 

,,       fistulse  of,  166 

,,       great  vessels  of,  137.  160 

,,       hydrocele  of,  167 

...       integuments  of,  139 

.,       lung  in,  145,  177 

„       lymphatic    glands    of,    163, 
164,  165 

,,       middle  line  of,  136 

,,       nerves  of,  13S 

,,       ribs  in,  145 

,,       side  of,  136 

,,       surface  anatomy  of,  135 

,,       wounds  of,  146 
Nelaton's  line,  424 
Nephrectomy,  366 
Nephrolithotomy,  366 
Nephroraphy,  366 
Nephrotomy,  366 
Nerve  stretching,  429 

,,      supply  of  lower  limb,  537 

>)  ,,  upper  limb,  275 

Nerves  (see  the  various  regions) 

,,      division  of  (see  the  various 
trunks). 

,,      of  the   spinal    cord,    their 
points  of  exit,  552 
Neuralgia,  facial,  99 

,,  of  scalp,  12 

Nipple,  176 

,,        in  groin,  433 
Nipples,  supernumerary,  178 
Nose,  81 


Nose,  cartilaginous  part  of,  83 
Notch  of  Rivini,  74 

Obturator  hernia,  309 

,,        nerve,  370,  442,  533 
,,        or   thyroid    dislocation, 
449,  454 
Occipital  bone  at  birth,  17 

,,  ,,    necrosis  of,  causing 

■wasting  of  tongue. 
122 
,,        glands,  163 
(Edema  of  the  glottis,  149 
(Esophagostomy,  160 
OEsophagotomy,  160 
CEsophagus,  158 

,,  cancer  of,  160 

,,  foreign  bodies  in,  159 

,,  nerve  supply  of,  160 

,,  operations  on,  160 

,,  relations  of.  159 

Olecranon,  232 

,,  fractures  of,  244 

Omega  loop  of  colon,  342 
Omental  hernia,  318 

,,        sac,  31S 
Omentum,  great,  317 
Ophthalmia,  sympathetic,  57 
Optic  disc,  5S 
,,      neuritis,  5S 
,,      thalamus,  37 
Ora  serrata,  58 
Orbicularis-palpebrarum .  G3 
Orbit,  41 
,,      abscess  of,  44 
,,      arteries  of,  45 
,,      dimensions  of,  41 
,,      fasciee  of,  42 
,,      fracture  of,  41 
,,      muscles  of,  44 
,,      nerves  of,  45 
,,      pidsating  tumours  of,  45 
,,      relations  of,  41 
Os  calcis,  dislocations  of  the,  518 
,,      ,,        fractures  of  the,  524 
,,  epactal,  18 

incisivum  in  hare-lip,  126 
,,  innominatum,  372,  375 
,,  magnum,  dislocation  of,  273 
Ovary,  414 

Pacinian  bodies  in  the  foot,  504 

,,  „        ,,        hand,  259 

Palate,  125 

„      cleft,  12G 

,,      hard,  127 

„       soft,  128 
Palmar  (see  Hand) 


IXDEX. 


;67 


Palmaris  longus  tendon,  523 
Pancreas,  359 
Pancreatic  cysts,  359 
Paracentesis  of   the    pericardium, 
1S4 
,,  thorax,  173 

,,  tympanum,  75 

,,  ventric  les    of 

brain,  37 
Paralysis  in  spinal  injuries,  553 

of  anterior  crural  nerve, 
533 
,,  cervical    sympathetic, 

47 
,,  external  popliteal 

nerve,  533 
.,  fourth  nerve.  4-'> 

,,  great     sciatic     nerve, 

033 
,,  internal    popliteal 

nerve,  533 
median  nerve,  280 
nmscuJo-spiral    nerve, 

270 
obturator  nerve,  533 
orbital  nerves,  4-3 
sixth  nerve,  46 
ulnar  nerve.  280 
Parietal  bone,  relationships  of,  36    . 

,,     fissures,  19 

Parieto-oceipital  fissure 

Parathyroid  bodies,  157 

Parotid  abscess,  103     ■ 

„      fascia,  103 

,,     gland,  107 

nerve  supply.  105 
,,      region,  103 

structures,  106 
,,      tumour,  107 
Patella,  413,  465,  473 

.,        dislocation  of,  4 S3 
fractures  of,  4:1 
Patellar  ligament,  465,  t7" 
Pelvic  arch,  372 

..      cellulitis,  313,  3S1 

fascia,  379 
,,     symphysis,  373 
Pelvis,  372 

,,      floor  of,  37;' 
,,      fractures  of,  373 

mechanism  of.  372 
,,      nerves  of.  420 
,,      vessels  of,  3S2 
Penile  urethra,  303 
Penis,  405 

,,       malformations  of,  400 
Perforating  ulcer,  504 
Pericardium,  tapping  of.  184 
Pericranium.  5 


Perineal  hernia,  310  ' 
Periuephritic  abscess,  362 
Perineum,  depth  of. 

,,         fascine  of.  385 
,,         mali 
,,         nerves  of.  420 
,;         vessels  of, 
Peritoneum,  310 

fossa:  of,  339 
Perityphlitis,  33S 
Peroneal  artery,  4'.»1 

,,        tubercle,  500 ; 
Peroneus  tertius,  501 
Petit's  triangle,  284,  313 
Petro-squamous  suture,  77i 
Phantom  tumour,  290 
Pharynx,  129 

,,         foreign  bodies  in,  130 
,,         mucous  membrane  of,  131 
,,         relations  of,  132 
Photophobia,  55 
Phrenic  nerve,  139,  SOS 
Pigeon  breast.  106 
Piles,  417 
Pinna  (see  Ear),  OS 
Pirogoffs  amputation,  529 
Plantar  (see  Foot) 
Plantaris tendon,  rupture  of.  492 
Plaques  des  funieurs,  121 
Platvsma  myoides,  139 
Pleura,  179 

„       wounds  of,  179,  ISO 
Pneumatocele,  7S 
Pneumo-thorax,  179 
Politzer's  method  of  inflating  the 

middle  ear,  79 
Pollock's  method    of  dividing  the 

muscles  of  the  palate.  128 
Polypus  of  nose. 
Popliteal  abscess,  470 
,,        bursas,  473 
,,        fascia,  470 

glands,  468,  473 
nerves,  429,  40s,  471,  333 
,,        space,  469 

vessels.  471,  492 
Post -nasal  growth! 
Pott's  disease  of  spine,  543 

,,  ,,       operations  in,  168,  "  15 

,,    fracture.  514 
Profunda  arteries  in  arm,  22 

,,         femoris,  432,  435 
Prolapsus  ani,  417 
Pronation,  movement  of,  249 
Pronator  radii  teres,  2 
Prostate,  39S,  415 
,,        abscess  of. 
„       hypertrophy  of,  399 
Prostatectomv,  400 


568 


Surgical  Applied  Anatomy. 


Prostatic  plexus  of  veins,  400 
Psoas  abscess,  313 

,,      muscle,  311,  434 
Pterion,  35 
Ptosis,  45 
Pubic  spine,  283 
Pudendal  hernia,  310,  412 
Pulmonary  apoplexy,  180 

,,  artery,  1S2 

Puncta  lachrymalia,  67 
Pylorus,  321,  326 

,,        resection  of  the,  327 

Radial  artery,  246,  268 

,,      nerve,  strength  of  the,  429 
Radius,  dislocations  of  the,  239,  240 
.,       fractures  of  the,  244,  250, 
.     270 
Ranula,  119 
Rectocele,  413 
Recto-vaginal  fistula,  413 
Rectum,  414 

,,        attachments  of  the,  417 
, ,        effects  of  distension  of,  41 6 
,,        foreign  bodies  in,  416 
, ,        of  infant,  414 
,,        introduction  of  hand  into, 

416 
,,        lymphatics  of,  418 
,,        mucous  membrane  of,  417 
,,        nerves  of,  419 
,,        serous  membrane  of,  415 
,,        vessels  of,  417 
Rectus  abdominis  muscle,  290 
Referred  pain,  296 
Renal  abscess,  363 
Resections  (see  the  various  parts) 
Respiration    in    fracture     of     the 

spine,  553' 
Retina,  58 

Retro-peritoneal  hernia,  334 
Rhinolithes  in  the  nose,  SS 
Rhinoplasty,  224 
Rhinoscopy,  84 
Ribs,  171 
,,     cervical,  145 
,,     excision  of,  174 
,,     fractures  of,  172 
Rickets,  effect  of,  on  pelvis,  373 
,,  ,,  the  ribs,  173 

,,  „  skull,  16 

„  ,,  tibia,  499 

Rider's  bone,  435 

,,       sprains,  435 
Riedel's  lobe,  350 
Rima  glottidis,  136,  149 
Rolando,  fissure  of,  35 
Rosenmtiller,  fossa  of,  SO 
Rouge's  operation,  S4 


Sacro-coccygeal  joint,  37S 
Sacro-iliac  synchrondrosis,  375 
Sacrum,  372 

j,        dislocation  of  the,  376 
Sagittal  fontanelle,  19 
Salivary  fistulse,  108 
Saphenous  opening,  432 

veins,  436,  459,  467,  493 
Sartorius  muscle,  431 
Scalene  muscles,  137, 140 
Scalp,  abscess  of,  6 

,,     dangerous  area  of,  3 
,,     fatty  tissue  in,  2 
,,     hsematoma  of,  7 
,,     its  mobility,  3 
,,     lymphatics  of,  15,  165 
,,     nerves  of  12,  14 
,,     neuralgia  of,  14 
,,     sebaceous  tumours  of,  2 
, ,     sutures  in  wounds  of,  3 
,,      suppuration  in  the,  6 
,,     temporal  region  of,  7 
, ,     A'ascularity  of  the,  4 
,,     vessels  of,  12 
,,      wounds,  4 
Scaphoid  bone,  dislocation  of  the, 

526 
Scapula,  186,  199 

,,       excision  of,  202 
,,       fractures  of,  200,  201 
Scai'pa's  triangle,  430 

,,  ,,        fascia  of,  433 

,,  ,,        glands  of,  436 

,,  ,,       vessels     of,    432, 

435 
Sciatic  artery,  425,  42S 
,,      dislocation,  449 
,,      nerve,  'great,  425,  42S,  444, 
•    535 
Sciatica,  42S 
Sclerotic,  50 
Scoliosis,  538 

Scrofula,  sign  of,  in  pinna,  09 
Scrofulous  pharyngitis,  131 
Scrotum,  406 

,,        and  elephantiasis,  407 

,,  ,,    oedema,  407 

,,        application  of  leeches  to 

the,  407 
,,        subcutaneous    tissue    of 
the,  407 
Semilunar  cartilages  of  knee,  dis- 
location of  the,  479 
Semimembranosus  tendon,  466,  470 
Sensori-motor  areas  of  brain,  37 
Septum  of  nose,  86 
Shoulder,  185 

,,         bursa:  about,  209,  211 
,,         dislocation  of  the,  214 


IXDEX. 


|69 


Shoulder,  fractures  about  the,  219 
,,        joint,  210 

,  ,,      amputation  at  the, 

222 
,  ,,      disease  of  the,  212 

,,        surface  anatomy  of,  ISO 
,,         tip  pain   from   liver  ail- 
ments, 369 
Sigaultean  operation,  375 
Sigmoid  flexure,  342,  369 
Sinus,  cervical,  167 
,,       lateral,  12 

,,       superior  longitudinal,  12 
,,       sphenoidal,  93 
Sinuses  of  skull,  12,  30 
,,      (air)  of  skull,  92 
Skull,  15 
,,      abnormalities  of,  18 
,,      deformities  of,  16,  IS,  21 
,,      development  of,  16 
,,      emissary  veins  of,  13 
,,      fractux-es  of,  20 
,,      necrosis  of,  5,  19 
,,      of  infant,  1(3,  19,  20,  21,  22 
,,      soft  parts  covering,  1 
,,      sutures  of,  15,  27 
„      thickness  of,  28 
,,      trephining  the,  S 

venous  tumours  of.  14 
Soft  palate,  12S 
Solar  plexus,  36S 
Soleus,  492 
Spermatic  artery,  410 
„  cord,  410 

,,  plexus  of  veins,  411 

Sphenoidal  sinus,  94 
Sphincter  ani,  3S4,  419 
Spina  bifida,  377 
Spinal  accessory  nerve,  14u 
,,      cord,  541,  545 
,,         ,,     concussion  of,  549 
,,         ,,      contusion  and  crush- 
ing of,  550 
,,         ,,     loss  of  motion  due  to 

injury  of  the,  553 
,,         ,,      loss  of  sensation  due 
to  injury  of  the,  553 
,,         ,,     operations  on,  555 

,,      wounds  of,  54  S 
,,      injuries  and  defalcation,  554 
,,  ,,  micturition, 

55  l 
,,  ,,  respiration,  553 

n  i)  vomiting,  555 

,,     meninges,  547 
,,     meningitis,  547,  548 

nerves,  distribution,  296 
1,         ,,      points  of  origin,  552 
Spine,  537 


Spine,  curves  of,  537 

,,      fractures    and    dislocations 

of,  540 
,,      scoliosis  of,  53S 
,,      sprains  of,  530 
,,     trephining  the,  545,  5">5 
Spinous  processes,  fracture  of,  544 
Splay  foot,  522 
Spleen,  355 

„       capsule  of  the,  357 
,,       dislocation  of,  350 
,,       enlarged,  35S 
,,       extirpation  of  the,  3";8 
,,       injuries  to  the,  357 
,,       relations  of,  355 
,,       rupture  of,  357 
St  en  son's  duct,  107 
Sterno-clavicular  joint,  105 

,,  disease  of,  196 

,,  dislocations      of, 

197 
,,  joint,  movements 

of,  195 
..     -mastoid    muscle,    130,   140, 

143,  144 
..     -xiphoid  joint,  109 
Sternum,  109 

,,        fractures  of,  170 

,,        holes  in,  171 

, ,        separation  of  segment  s  of. 

171 
,,        trephining  the,  171 
stomach,  321 

,,        displacement  of.  323 

fistula?  of,  324 
,,        foreign  bodies  in,  324 
hernia  of.  323 
lymphatics  of,  326 
,,        operations  on,  320,  32s 
,,        ptosis  of,  323 
„        relations  of,  321.  323 
,,        vertical,  323 
,,        wounds  of  the,  323 
Strabismus,  43,  45 
Subacromial  bursa,  211 
Subarachnoid  space,  30,  547 
Subastragaloid  amputation,  531 

,,  dislocations  of  the 

foot,  519 
Subclavian  artery,  13S,  101 

,,  vein,  138,  190 

Subclavicular  fossa,  187 
Subclavius  muscle,  190 
Subdural  space,  30,  547 
Sublingual  bursa  mucosa,  119 
,,  gland,  11^ 

,,  papilla.  1  Is 

Submaxillary  glands,  10;; 
Suboccipital  nerve.  162 


57° 


Surgical  Applied  Anatomy. 


Subserous  connective  tissue  of  the 
abdomen,  291 

Sulci  of  brain,  relations  of,  33 

Superficial  cervical  glands,  163 

Superior  maxilla,  108 

cleft  of,  126 
,,  ,,        excision  of    the, 

109 
,,  ,,        fractures  of,  10S 

,,  ,,        necrosis  of,  109 

,,      thyroid  artery,  137 
,,      vena  cava,  182 

Supination,  movement  of,  249 

Supinator  longus,  232 

Supraclavicular  nerves,  190 

Supracondyloid  process,  226 

Suprahyoid  glands,  163 

Supraorbital  foramen,  99 

Suprapubic  lithotomy,  390 

Sustentaculum  tali,  500 

,,  fracture  of,  525 

Sutures  of  skull,  15,  18,  27 
,,  ,,  closure  of,  22 

,,  ,,  position  of,  15 

,,  ,,  relations     of,     to 

brain,  32 
,,  ,,  relations     of,    to 

surface,  15 
„  ,,  separation  of,  27 

Sycosis,  64 

Sylvius,  fissure  of,  35 

Symblepharon,  65 

Syme's  amputation,  528 

Sympathetic  ophthalmia,  57 

Symphysis  of  pelvis,  375 

Synostosis  of  skull,  22 

Synovial  cavities  of  the  foot,  527 
,,  ,,  ,,       hand,  273 

,,        sheaths  in  the  hand,  264 

Synovitis,  acute,  in  the  hip-joint, 
439 
,,  „      in  the  knee,  477 

Tabatiere  anatomique,  258 
Tagliacozzi's  operation,  224 
Talipes  calcaneus,  521 

,,       cavus,  505 

,,       equinus,  520 

,,      and  the  plantar  fascia,  505 

,,       mixed  forms  of,  522 

,,      valgus,  521 

,,      varus,  521 
Tarsal    bones,    fractures  and    dis- 
locations of,  525] 

,,       cartilage,  63 

,,  cyst,  64 
Tarsectomy,  522 
Tarsus  (see  Foot) 
Taxis,  309 


Teeth,  116 

,,      wisdom,  116 
Temporal  abscess,  8 
,,        fascia,  7 
,,         fossa,  7 
Temporo  -  maxillary     articulation. 
112 
,,        -maxillary     articulation, 
dislocations  at,  112 
Tendo  Achillis,  486,  503,  511 

,,     oculi,  66 
Tenon's  capsule,  42 
Tenotomy  and  the  peroneal  nerve, 
471 
,,        of  hamstrings,  471 
,,  sterno-mastoid,  140 

Tensor  palati,  128 
Testicle,  408,  421 

,,        descent  of,  302 
,,        fungus  of,  409 
,,        in  the  foetus,  302 
,,        inversion  of,  409 
,,        investments  of,  408 
,,        nerves  of,  421 
,,        tunic  of,  409 
Thecal  abscess,  265 
Thenar  eminence,  255 
Thigh,  458 

,,      amputation  of  the,  464 
,,      fasciae  of,  459 
,,      fractures  of,  461 
,,      integuments  of,  459 
,,      muscles  of,  460 
,,       surface  anatomy  of,  458 
Thoracic  duct,  166,  184,  371  ^ 
Thoracoplasty,  174 
Thorax,  168 

,,       deformities  of,  169 
,,       paracentesis  of,  173    , 
,,       viscera  of,  178 

walls  of,  168 
,,       wounds  of,  183 
Thumb,  amputation  of  the,  275 

„       dislocation  of,  273 
Thymus,  154 
Thyroid  body,  136,  137,  155 

,,        ,,        accessory  glands  of, 

124,  156 
,,        ,,        development  of,  156 
,,        ,,        excision  of,  157 
,,        ,,        in  tracheotomy,  153 
,,       cartilage,  136,  149 
,,       nerves  of,  157 
Thyroidea  ima  artery,  153,  158 
Tibia  and  fibula,  fractures  of,  495 
„    fractures  of,  487,  497 
,,     in  rickets,  499 
,,     shaft  of,  its  strength,  495J 
Tibial  vessels,  492,  508 


Index. 


57i 


Tibialis  anticus  muscle,  190 
Tongue,  L20 

,,        accessory    glands     about, 

L24,  156 
,,        dermoid  cyst  of,  124 
,,         blood  supply  of,  121 
,,        epithelium  of,  121 
,,        excision  of,  124 
,,        lymphatics  of,  123 
,,        mucous  cysts  of,  121 
,,        nerve  supply  of,  122 
Tongue-tie.  121 
Tonsil,  132 

,,       bleeding  from,  134 
,,       foreign  body  in,  134 
,,       hypertrophy  of,  133 
.,  ,,  an'd  deaf- 

ness. 133 
„       lingual,  123 
,,       Luschka's,  SO,  131 
„      pharyngeal,  80,  131 
Trachea,  130,  148,  152,  181 

,,        foreign  bodies  in,  1-34,  182 
Tracheotomy,  151,  152 
Transverse  cervical  artery,  138 
„  colon,  340,  341 

,,         process  of  the  atlas,  135 
,,  .,  cervical     ver- 

tebne,  135 
Trapezium,  258 

Trendelenburg's  operation,  376 
Trephining,  8,  549 

.,  for  intracranial  abscess, 

10 
Triangular  ligament  of  the  urethra, 

379,  386 
Trigone,  395 
Trismus,  115 
Tubera  ischii,  372,  42  1 
Tunica  abdominalis,  286 
,,      albuginea,  40;> 
,,      vaginalis,  303,  40* 
Tympanum,  75 

Ulna,  dislocation  of  the,  23S 

,,     fracture  of  the,  250 
Ulnar  artery,  247 

,,      nerve,  224,  235,  2S0,  429 
,,      vein  in  venesection,  233 
Umbilical  fistula,  289 

,,         hernia,  288,  310 
Umbilicus,  fibrous  ring  of,  288 
,,  position  of,  2S3 

,,  vessels  of.  293 

Umbo  of  membrana  tyrapani,  71 
Urachus,  28S 
Ureter,  307 

,,      and  regurgitation  or  urine. 
397/ 


Ureter,  distension  of.  367 

,,       resection  of.  368 
,,       rupture  of,  367 
Urethra,  female,  405.  42J 
,,         male,  400,  421 
,,  ,,      curve  of,  401 

,,  ,,      membranous,  401 

,,        mucous  membrane  <»1.  404 
,,        narrowest  parts  of,  403 
,,        penile,  400 
„        prostatic,  400 
,,        rupture  of  the,  404 
(  rethral  triangle,  385,  380_ 
Uterus,  413 

.,       lymphatics  of.  414 
Vagina,  412 
Vaginal  cystocele,  413 
Valsalva's  method  of  inflating  tic 

middle  ear,  79 
Varicocele,  411 
Varicose  veins,  411,  493 
Vas  deferens,  410 
Veins  (see  various  parts) 
„    air  in,  163,  207 
,,     emissary  of  skull,  13 
,,     of  diploe,  13 
Venesection  at  the  elbow,  234 
,.  in  the  foot,  509 

,,  on  the  arm,  234 

Venous  tumours  of  skull,  14 
Vermiform  appendix,  338 
Vertebra,  caries  of,  316 

,,        prominens,  135 
Vertebral  artery,  162 

,,         column,  537 
Vesicovaginal  fistula,  413 
Vitello-intestinal  duct,  2S9,  337 
Vitreous  humour,  59,  60 
Volvulus  of   the  sigmoid    flexure, 

343 
Vulva,  412 

Wardrop's  operation,  161 
"Weaver's  bottom,  427 
Wharton's  duct,  US 
White  line  at  anus,  419 

,,         in  the  pelvic  fascia,  380 
Whitlow,  265 
Wormian  bones,  19 
Wrist,  253 

,,     joint,  255,  268 

,,        ,,      amputations  at,  274 

,,        ,,      dislocations  at,  272. 

,,        ,,      fractures  about,  270 
,,      movements  at,  268 
Burfa.ce  anatomy  of  the.  253 
Wry  neck,  140 

Zygoma,  fracture  of,  12 


PlUNTED    BY 

Cassell  &  Company,  Limited,  La  Belle  Sauvage, 
London,  E.C. 


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